Prenatal Record - National Archives and Records Administration

PAST MEDICAL HIS'roRY
(For Form OB-6, Rev. 11-59)
rnSTRUCTIONS FOR INTERVIEWli
Item 2.
"History Taken Bv" Write your first and last name clearly.
Item J. This space is for Central Office use.
Item 4.
"lak" Record the· date this history was obtained.
Item 5. "List H9spitalizatipns 11 Include here all hospitalizations which were not
listed on OB-2 or OB-5. This will include all hospitalizations (not for
previous pregnancy) which occurred more than one year ago. Admissions to
sanitaria and mental hospitals should be reported here (or on OB-5 if
occurring during the past year). If there were no such hospitalizations,
mark the box for ''None. 11
Item 6.
Item 7.
Item 8.
"~"Record the patient's best approximation or month and year.
"Hospital" Record the name and address or location or the hospital, with
sufficient accuracy, it possible,. to establish a mailing address. If at
this hospital, or a~ associated hospital using the same record room,
record "Here."
"Reasgn" Determine the diagnosis or complaint if possible. Inquire
specifically about any op~ration that may have been performed and note the
procedure here.
Item 9.
"Radiologic EIAm'n•tiOl.,;, .2r Treatments During Past 12 Months" This includes
the diagnostic use ot radioisotopes. A history or X-ray since L.M.P., noted
on OB-J, should be reported here also. It need not be described in detail
on OB-J, but should always be described here.
X-rays obtained through this obstetric clinic after the patient is
registered in the Study should ~be reported either here or on OB-J, but
only on OB-10, 11, ana other appropriate clinical records.
If the patient reports no radiation exposure in the 12 months preceding
date of registratiop in the Study, check the box marked "None."
Item 10.
Item 11.
Item 12.
"~"Record month numerically and year in two digits ('60, 1 61, etc.).
"Singe Pregnancy" It the exposure was before LMP (or estimated date of conception
it LMP is not related to onset or pregnancy), mark "No." If after
LMP, mark ''Yes."
"Chest X-Ray" Mark. "Yes" if the exposure was a routine chest x-ray (either
standard or miniature film). In this case items no. lJ and 14 should be
left blank.
Mayl961
Reproduced at the National Archives
II.A.l08
OB-6