Prenatal Record - National Archives and Records Administration

ADMINISTRATIVE RECORD MANUAL
PHS-3003-1, Obstetrical Administrative Record
AR-1
Rev. 7-6o
Item 9, Address.
Self-explanatory.
Item 10, Telephone Number. Self-explanatory. If none, state "none" or
leave blank.
Item 11, EDC. Expected date of confinement. This item is to be completed
only if needed by hospital.
Item 12, Date Registered. Date patient was first seen in the clinic whether
or not Form AR-1 is started on this date. Record all dates numerically,
in the order month-day-year as 9-15-59· This item should also be completed
for non-study sampling frame patie~ts {i.e., not selected for study).
Item 13, Date Form Initiated. Date that this form is started, which may
be prior or subsequent to the date of registration {Item 12). For many
hospitals it will- be the same as the date shown in Item 12.
Item 14, First-Day LMP. Record the date of first day of the last normal
menstrual period. If unknown, record as "X" and record the best availa:.~e
estimate of EDC in Item 11. If the date given is obviously not for this
pregnancy, give the date with an asterisk {*) next to it and in Item 11
{EDC) record the best known estimate of the date of confinement. If not
available at time of report submit at a later date as a correction to the
form.
Item 15, Date of Birth.
help of patient.
If unknown, attempt to estimate year of birth with
Item 16, Age. Age at last birthday. This item is to be completed only if
needed by hospital.
Item 17, Marital Status ..This item is to be used to record, where possible,
the legal marital status of gravida and non-legal relationships should
be ignored. Check appropriate box. The abbreviations on the form represent
the following classifications:
S - Single {never married)
M - Married
CL - Common Law ?-!arriage - Use this category if it is
in general use in your institution and it is a
legal marital status in your community.
W - Widowed
SEP - Married but separated. Include all patients who
are married but not living with husband whether or
not the separation is legally recognized.
Department of Health, Education and Welfare October 1, 1960
Public Health Service
II.A.ll
AR-1
Reproduced at the National Archives