Prenatal Record - National Archives and Records Administration

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Reproduced at the National Archives nata Ite~s RPfPrenclnq fnr~ nB-3, HistorY ~ince ~ast ~PnStruat Perf~~ DATA Tr~!4 ITEM JN CIIRO TO F'JIUI NIIM FROIC TI'J DA rA TTF.M IU14F.: 2,;s ••• o~-1 4l 0101 61 64 Smo~inq history, nu~oPr s~~l 65 Phy~ici~n vfsftej 2ft7 ••••••• 0303 66 ~0 BlanK 49A5 •••• VAR 43 5? ~3 s~o~inq htstorv: cl :uret tes ol"r :H1y now, nu111ber 49R7 •••• VAR 4 5'> ~6 Prenatal visits, tot a 1 nu'lloer 49R8 •••• VA~ H 57 c;a smol • ~ 0 @ I w
eoL"-aooa.a ACV. n-et • HISTORY SINCE LAST MENSTRUAL PERIOD (lnteme...rJ 2. HISTORY TAKEN BY 3. I. PATtENT IDENTIFICATION •• DATE 5. NEXT SCHEDULED VISIT I I I ; I I I I I I I Mo. I D•l' I Y••r Mo. I Day I y ... •• CHECK APPROPRIATE COt..UMN NO YES 0 1 S. FELT SICK IN ANY WAY X X XX : 7. HEADACHE 8. VISUAL DISTURBANCE 9, WEAKNESS, NUMBNESS, DIZZINESS 10, VOMITING 11. PAIN: ABDOMEN, PELVIS, BACK 12. URINARY URGENCY, DYSURIA i 13. DIARRHEA ' 1•• COLO, SORE THROAT, COUGH 1!, FEVER 18. EYE INI"LAMMATION 17. RASH OR SKIN TROUBLE 18. JAUNDICE .7. LIST BY NUMBf:R AND DESCRIBE ANY CONDITION NOTED PRESENT AT LEFT WITH APPROXIMATE DATE OF ONSET, DURATION AND SEVERITY. 11. SWOLLEN GLANDS 20. COLO SORES 21, BOILS OR ABSCESSED TEETH . 22. EARACHE I 23. SWELLING 01" I"EET OR LEGS i 2., SWELLING 01" HANOI OR I" ACE ZS. VAGINAL BLEEDING Zl. I"AINTING 27. CONVULSIONS 28. ACCIDENT, POISON, INJURY 21. OfOERATION 30. RADIATION, X-RAY 31. AIR TRAVEL 32. INJECTION, VACCINATION 33, INI"ECTIOUI DISEASE IN HOME 3•• SICK PET IN HOME 31. WORKS OUTSIDE HOME 3~ INTERCOURSE FREQUENCY (Total nYDNr ot tlrnee ~ laat _.Ill) .. 37. EVER SMOKED 38. SMOKED AT 31. TOTAL YEARS LEAST 5 PACKS SMOKED 0YO:S QNo Qyu ONo ' ' .0. AGE STARTED • •• AGE STOPPED U. LARGEST REGULAR DAILY AMOUNT U. NO. 01" CIGARETTES SMOKED PER DAY NOW ••· PHYSICIAN VISITED !Mual k c..uaolecO 0 NO • G. NAME 01" PHYSICIAN QYU I ••• ADDRESS COL.LAaO.. ATIVIE JIIII:IEAJIICH (RII:V. ,..91 ~IEfUNATAL JIICS&AftCH 8JIIANCH, NINa•• NIH 08-3 81ETHIESOA 1., MO. II.A.41 OB-3 Reproduced at the National Archives
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NINCDS COLLABORATIVE PERINATAL PROJ
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NINCDS COLLABORATIVE PERINATAL PROJ
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INTRODUCTION DOCUMENT OBJECTIVES AN
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Forms The first forms used in the s
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Reproduced at the National Archives
Page 11 and 12: selection. A n1n was used for patie
Page 13 and 14: , researcher is more likely to look
Page 15 and 16: TABLE 3. Abbreviations for Person,
Page 17 and 18: TABLE 4. Definition of Person, Time
Page 19 and 20: TABLE 4. Definition of Person, Time
Page 21 and 22: CONTENTS AR-1/0B-1 OB-2 OB-3 OB
Page 23 and 24: AR-1 Obstetrical Administrative Rec
Page 25 and 26: Reproduced at the National Archives
Page 29 and 30: DEFINITION OF CODES {Continued) FOR
Page 31 and 32: ... 1;:: I ~ .J.I'40JI.!9d jl5 !
Page 33 and 34: ADMINISTRATIVE RECORD MANUAL PHS-30
Page 35 and 36: ADMI!liSTRATIVE RECORD ;fl.A.TI.TUA
Page 37 and 38: -· IID'~7-- '·"'-- ':!e- ~ l·-~
Page 39 and 40: OB-1: OBSTETRICAL· ADMINISTRATIVE
Page 41 and 42: Par. 3 10 - Religion. Record as Cat
Page 43 and 44: OB-2 Reproductive History Form OB-2
Page 47 and 48: COLIII:•IOoa-& ,.., REPRODUCTIVE
Page 51 and 52: DEFTIITTION OF CODES (Continued) FI
Page 53 and 54: 1 Reproduced at the National Archiv
Page 55 and 56: R~PRODUCTI\~ HISTORY (Con't.) C3-2
Page 57 and 58: REPRODUCTIVE HISTORY (Con•t.) C3-
Page 59 and 60: OB-3 History Since Last Menstrual P
Page 61: Reproduced at the National Archives
Page 67 and 68: DEFINITION OF CODES (Continued) FOR
Page 69 and 70: DEFJNITION OF CODES (Continued) FOR
Page 71 and 72: "' 1: : ~~ :; "':J. !~ ~ ~ :~ ~ ; :
Page 73 and 74: HISTORY SINCE LAST 1-ENSTRUAL PERIO
Page 75 and 76: HISTORY SINCE ~T MENSTRQ~ P~RIOD {C
Page 77 and 78: OB-4 Gynecological History Form OB-
Page 81 and 82: COL.,.-aaaa-4 RIEV. tt-11 • GYNEC
Page 83 and 84: DEFINITION OF CODES GYNECOLOGICAL H
Page 85 and 86: DEFINITION OF CODES (Continued) FIE
Page 87 and 88: '? I~ 1: :1\ j; t:: t; ....J 7 ,.
Page 89 and 90: GY1~F..COLOGICAL HISTORY (Con't.) O
Page 91 and 92: 08-5 Recent Medical History Form 08
Page 99 and 100: DEFINITION OF CODES RECENT MEDICAL
Page 101 and 102: DEl!'INITION OF CODES (Continued) F
Page 107 and 108: ILL..'1ESS OR DISABILITY CODES (Con
Page 111 and 112: RECENT MEDICAL HISTORY (Con 1 t) OB
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OB-6 Past Medical History Form OB-6
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z PAST MEDICAL HISTORY (Interviewer
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DEF'll'UTION OF CODES PAST MEDICAL
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DEF'INli'ION OF CODES (Continued) F
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DEFINITION OF CODES (Continued) u.
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DEFINITION OF CODES (Continued) FOO
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PAST HEDICAL HISTORY (Con't) Item 1
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HISTORY TAKEN BY PAST MEDICAL HISTO
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OB-7 Infectious Disease and System
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COLIII.•I00 ..7 ,... INFECTIOUS D
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C:OLft-IOOa-7 1··· INFECTIOUS DI
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DEFINITION OF CODES nlFECTIOO'S DIS
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DEl''ll'IITION OF C:JDES ( Conti:::
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i i :a :: ·• 1: !: ! I! ::
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l!:i i!;T!IJIJ;: IIJ;;:..f,;:l·: .
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INF~TIOUS DIS~S~ ;~D SYSTEM REVIEW
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OB-8 Repeat Prenatal History Form O
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I. ftATIIMT IDfNTIPICATIOM REPEAT P
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DEFINITION OF CODES (Continued) FOR
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DEFINITION OF CODES (Continued) FIE
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~ :: : j: ~ : I~ =r ; Ia ~ ~ !~ ;
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,;.-~ 1•1. 1J;,.... - ~ .. u;W'o'
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OB-9 Prenatal Record Form OB-9, Pre
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C:OL.II.·- I•It NU\E IHOSPITAL
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•• 'HISTORY NO. diRIRXL IXXMI l
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~~J2ITTIGN OF CODES (Co~~i~ued) FCa
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DEFINITION OF CODES (Continued) FOF
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DEF~~ION OF CODES (Continued) PELVI
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DEFTIHTION OF CODES (Continued) FQR
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ZEFT1ITTIO:i OF CODES (Con"'c:..!!U
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DEFINITION OF CODES ( Con~inued) FC
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:t , I~ I ~ It II! I~ ::: .. ~ .. ~
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!:: llil\41.0 ~ ~~ ~'~"'~ -N OB-9 -
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PRENATAL RECORD (Con 1 t) PRESENT P
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PRENATAL RECORD (Con 't) complete a
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PRENATAL RECORD (Can't) EVALUATION
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PRENATAL RECORD (Con't) GENERAL IDl
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OB-42 Past Medical History Form OB-
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-· eoL"-aooa-..a 08-42 PAST MEDICA
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Instruction Manual for Obstetric Fo
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OB-43 Initial Prenatal Examination
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COL ..-3008-41 UIIYe 10.U) 1. PATIE
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DEFINITION OF CODES miTIAL PRENATAL
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DEFINITION OF CODES (Continued) FOB
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DEF'INITION OF CODES (Continued) FO
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I ,rnrn:r s YIN.Ct:l S6¥:;~rn I
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I, I'ATIENT IDENTI,.ICATIDN OB-43 I
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OB-10 Return Visit and Laboratory R
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DEFTIUTION OF CODES (Continued) FOR
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DEFINITION OF CODES (Continued) FOB
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4/16/61 OB-10 RETURN VISIT AND LAB
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~"........ ,... ~,_~.a., RETURN VIS
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OB-44 Prenatal Observations Form OB
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..... C:Ol..llt-IOOa-44 1. PATIENT
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:FDRMS 03-10 DEFINITION OF CODES (C
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DEFINITION OF CODES (Continued) ~·
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Instructional Manual for Obstetric
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OB-45 Laboratory Record Form OB-45
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DEFllUTION OF CODES LABJRATORY RECO
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DEFJNITION OF CODES (continued) FIE
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DEFINITION OF CODES (continued) FOR
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DEFINITIDN OF CODES (continued) FOR
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DEFTIUTION OF CODES (continued) FOR
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DEFINITION OF CODES (continued) FIE
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DEFINITION OF CODES (continuted) FI
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DEFTIHTION OF CODES (continued) FIE
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DEFTIUTION OF CODES (continued) FIE
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OB-11 Record of Current Pregnancy F
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CO~A·3C03·11 lltEV. '7·58 I. PAT
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RECORD OF CURRENT PREGNANCY (For Fo
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,... RECORD OF CURRENT PREGNANCY IN
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OB-46 Physician•s Clinic Record,
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COLR-1001-4e 4-a I. PATIENT IDENTII
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Instruction :\l:J.nual for Obstetri
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OB-12 Summary of Hospitalization fo
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SUMMARY OF HOSPITALIZATION FOR ANY
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SUMMARY OF HOSPITALIZATION FOR ANY
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':.::-•••suMMARY OF HOSPITALI
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OB-47 Summary of Antepartum Hospita
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· COLIII-IOOa..7 (CHANGIED 2-8a)
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OB-15 Drugs in Pregnancy Form OB-15
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PH S.300S.18 ..... PATIENT IDENTIFI
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.... PMS•3003•18 PATIENT IDENTI
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PHI·IOOI .. 1B P"TIENT IOENTIFIC"T
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PATI~NT IDENTIFICATION OB-15 DRUGS
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..... PHS .. 3003 ... 11 PATII!NT I
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DEFINITION OF CODES DRUGS lN PREGN
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Drugs in Pregnancy (08-15) Blank 0
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Drugs in Pregnancy (cont.} 2128 Par
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Orugs in Pregnancy (cont.) 4256 Hyo
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. Drugs in Pregnancy (cont.) 7154 S
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1 Drugs in Pregnancy (cont.) 7482 O
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Drugs in Pregnancy (cont.) 9169 917
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Drugs in Pregnancy (cont.) 9949 995
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