Prenatal Record - National Archives and Records Administration

GY1~F..COLOGICAL HISTORY (Con't.) OB-4
Rev. 11/59
Item #13 "Exoected Date of Confinement"
Record the expected date of confinement (in the order month, day, and year)
obtained by adding seven days to the first day of the last normal menstrual
period, adding one year, and counting back three months. If this is
obviously not correct, record the obstetrician's estimate instead.
Item #14 "Dysmenorrhea"
Ask the patient if she has any discomfort with her periods. If she has
none, check "None 11 • If the patient notes some discomfort, but takes no
medication (not even aspirin), check "Slight". If the patient has discomfort
which requires medication but is able to continue with her usual
·activities, check "Moderate". If the patient's discomfort is such that
she must remain in bed or away from gainful employment for at least one day,
check "Severe".
Item #15 FERTILITY
Item #16 "Have you been Trying to Become Pregnant?"
Ask the patient if she has been trying to become pregnant. If she says
"yes", ask question #17, "How long did it take you to become pregnant?"
The answer is to be determined in months. If the patient says "no" to
Item #16 1
ask Item #18, "If no, do you usually use a contraceptive?"
Record "yes" or "no".
Item #19 "Were you Using a Contraceptive at the Time You Became Pregnant?"
This must be asked of all patients. This refers to the actual exposure
at which the patient believes she conceived. Record "yes" or "no 11 • If
the patient does not know whether a contraceptive was used at the actual
time she conceived, write "UNK" in the space to the right. If the patient
answers "no", omit Item #20. If the answer is "yes" ask what contraceptive
the patient was using, and check more than one contraceptive if
more than one was used at the same time.
Item #21 "Sterility Investigation"
Inquire whether the patient has ever been examined to determine why she did
not become pregnant. If the patient did not go to the doctor specifically
for this, check "no". If she has gone to the doctor to see why she did not
become pregnant, check "yes" and obtain all information possible regarding
what the doctor did in the way of investigation.
II.A.67
February 1959
(For Forms in Use April 1961)
OB-4
Reproduced at the National Archives