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Maternal History Interview

This document appears to be a template for recording a maternal history interview. It includes fields for the mother's name, baby's gender, age, address, contact details, and obstetric history. It also includes checkboxes to indicate any pre-existing medical conditions the mother may have, such as cough/colds, asthma, UTIs, hepatitis B, and others. Space is provided to note medications, dates, and details. The bottom includes signatures for the interviewing pediatrician and person who conducted the interview.

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aringkinking
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86 views4 pages

Maternal History Interview

This document appears to be a template for recording a maternal history interview. It includes fields for the mother's name, baby's gender, age, address, contact details, and obstetric history. It also includes checkboxes to indicate any pre-existing medical conditions the mother may have, such as cough/colds, asthma, UTIs, hepatitis B, and others. Space is provided to note medications, dates, and details. The bottom includes signatures for the interviewing pediatrician and person who conducted the interview.

Uploaded by

aringkinking
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MATERNAL HISTORY INTERVIEW

Name of Mother: _________________________________ Name of Mother: _________________________________ Name of Mother: _________________________________


Gender of baby: __________________________________ Gender of baby: __________________________________ Gender of baby: __________________________________
Age: _______ Age: _______ Age: _______
Address: ________________________________________ Address: ________________________________________ Address: ________________________________________
Contact No: ________________ Contact No: ________________ Contact No: ________________
AOG: AOG: AOG:
G___ P___ BOW Intact G___ P___ BOW Intact G___ P___ BOW Intact
Ruptured Time: __________ Ruptured Time: __________ Ruptured Time: _________
Leaking Color: _________ Leaking Color: _________ Leaking Color: _________

Maternal Hx Maternal Hx Maternal Hx

( ) Cough and colds When: _______________ ( ) Cough and colds When: _______________ ( ) Cough and colds When: ________________
( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____
( ) Allergy ( ) Allergy ( ) Allergy
( ) HPN ( ) HPN ( ) HPN
( ) Cardiovascular Dse ( ) Cardiovascular Dse ( ) Cardiovascular Dse
( ) Goiter ( ) Goiter ( ) Goiter
( ) DM ( ) DM ( ) DM
( ) UTI When: ________________ ( ) UTI When: ________________ ( ) UTI When: ________________
( ) HepB Medications taken: ( ) HepB Medications taken: ______ ( ) HepB Medications taken: ______
______
Others: Others:
Others:

OB/PEDIA:____________________ OB/PEDIA:____________________
OB/PEDIA:____________________ Interviewed by:_______________ Interviewed by:_______________
Interviewed by:_______________
MATERNAL HISTORY INTERVIEW

Name of Mother: _________________________________ Name of Mother: _________________________________ Name of Mother: _________________________________


Gender of baby: __________________________________ Gender of baby: __________________________________ Gender of baby: __________________________________
Age: _______ Age: _______ Age: _______
Address: ________________________________________ Address: ________________________________________ Address: ________________________________________
Contact No: ________________ Contact No: ________________ Contact No: ________________
AOG: AOG: AOG:
G___ P___ BOW Intact G___ P___ BOW Intact G___ P___ BOW Intact
Ruptured Time: __________ Ruptured Time: _________ Ruptured Time: _________
Leaking Color: _________ Leaking Color: _________ Leaking Color: _________

Maternal Hx Maternal Hx Maternal Hx

( ) Cough and colds When: _______________ ( ) Cough and colds When: ________________ ( ) Cough and colds When: ________________
( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____
( ) Allergy ( ) Allergy ( ) Allergy
( ) HPN ( ) HPN ( ) HPN
( ) Cardiovascular Dse ( ) Cardiovascular Dse ( ) Cardiovascular Dse
( ) Goiter ( ) Goiter ( ) Goiter
( ) DM ( ) DM ( ) DM
( ) UTI When: ________________ ( ) UTI When: ________________ ( ) UTI When: ________________
( ) HepB Medications taken: ( ) HepB Medications taken: ( ) HepB Medications taken:
________________ ________________ ________________
Others: Others: Others:

OB/PEDIA:____________________ OB/PEDIA:____________________ OB/PEDIA:____________________


Interviewed by:_______________ Interviewed by:_______________ Interviewed by:_______________
MATERNAL HISTORY INTERVIEW

Name of Mother: _________________________________ Name of Mother: _________________________________ Name of Mother: _________________________________


Gender of baby: __________________________________ Gender of baby: __________________________________ Gender of baby: __________________________________
Age: _______ Age: _______ Age: _______
Address: ________________________________________ Address: ________________________________________ Address: ________________________________________
Contact No: ________________ Contact No: ________________ Contact No: ________________
AOG: AOG: AOG:
G___ P___ BOW Intact G___ P___ BOW Intact G___ P___ BOW Intact
Ruptured Time: __________ Ruptured Time: __________ Ruptured Time: _________
Leaking Color: _________ Leaking Color: _________ Leaking Color: _________

Maternal Hx Maternal Hx Maternal Hx

( ) Cough and colds When: _______________ ( ) Cough and colds When: _______________ ( ) Cough and colds When: ________________
( ) Asthma Medications taken: ( ) Asthma Medications taken: ( ) Asthma Medications taken:
( ) Allergy _______________ ( ) Allergy ________________ ( ) Allergy _________________
( ) HPN ( ) HPN ( ) HPN
( ) Cardiovascular Dse ( ) Cardiovascular Dse ( ) Cardiovascular Dse
( ) Goiter ( ) Goiter ( ) Goiter
( ) DM ( ) DM ( ) DM
( ) UTI When: ________________ ( ) UTI When: ________________ ( ) UTI When: ________________
( ) HepB Medications taken: ( ) HepB Medications taken: ( ) HepB Medications taken:
________________ ________________ ________________
Others: Others: Others:

OB/PEDIA:____________________ OB/PEDIA:____________________ OB/PEDIA:____________________


Interviewed by:_______________ Interviewed by:_______________ Interviewed by:_______________
MATERNAL HISTORY INTERVIEW

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