|
Visit Date
|
Gestation (wks):
|
|
Urine Protein
• • •
|
Urine Sugar
• • •
|
|
Urine Leucocytes
• • •
|
Urine Nitrates:
• • •
|
|
Blood Pressure
/
|
Repeat Blood Pressure
/
|
|
Weight (lbs)
|
|
|
Fundal Height (cm)
|
Presentation
• • •
|
|
FHR
|
Fetal Movement
|
|
Labor signs?
|
Cervix Exam
|
|
Edema
• • •
|
Pain Scale
|
|
NST Reactive?
|
AFI
|
|
RTC
• • •
|
Provider Initials
• • •
|
|
Discussed
• • •
|
Comments:
|
|
Subjective
• • •
|
Comments
|
|
Objective
• • •
|
Comments
|
|
Assessment
• • •
|
Comments
|
|
Plan
• • •
|
Comments
|
