Prenatal Record - National Archives and Records Administration

HISTORY SINCE LAST MENSTRUAL PERIOD {Con't.)
carefully.
If the patient has suffered an injury, give the site and extent. Note any
complications of the healing process.
Item #29 "Operation"
Attempt to provide answers to the following questions, in addition to date:
1. Hospital in which performed (if not in hospital, so note).
2. What was the condition necessitating the operation?
J. What operative procedure was done?
4· 'Was anesthesia given? If so, was -it local or general?
Item #30 "Radiation. X-R§y 11
If an examination, note the type of examination and attempt to determine
why it was done. If the patient has had therapeutic x-ray, record the site
and reason if this can be determined. Also note the hospital in which such
treatment was received or the physician who gave it (see Item #44).
Item #31 "Air Travel"
Do not record any air travel that occurred prior to the last normal menstrual
period. If the patient has traveled by air since that time, give the dates
of all flights and the points of departure and destinations.
Item #32 "Injection. vaccination"
Record the date, the suhatance (if known) and the reason for the injection
or vaccination as best determined by you.
Item #33 "Infectious Disease in lfpme 11
·.This item .attempts to establish any close contact that the gravida may have
had with acute infectioue diseases, particularly those of virus etiology.
Inquire about any illneu of anyone in the gravida's household. Attempt to
answer the following q~tians:
1. What is the relationship of persons ill?
2. 'Was a doctor consulted?
J. If he made a diagnosis, what was it? Otherwise, what does the gravida
think it was?
4· 'What were the principal symptoms?
5. 'What was the date of onset and duration for each person ill?
Item #34 "Sick Pet in Home"
Exposure to diseases of animals may be of significance in the etiology of
pregnancy wastage. It is desirable to have a record of all close contact
by the gravida with warm-blooded animals (i.e. birds and mammals). Do not
Reproduced at the National Archives
II.A.52
February 1959
(For Forms in Use April 1961)
OB-3