Pregnancy certificate


1.

Name and surname:

Birth Number Mother: When were you born?

Birth Number Father: When was your husband born?

Address:

Insurance: Do you have insurance in the Czech Republic? What´s your insurance number?

Outpatient care: Who is your gynecologist? What is his/her address? What is his/her name?

Number of pregnancies: What´s the number of your pregnancy?

Have you been pregnant before? Are you pregnant for the first time?

How many times did you give birth? PREGNANCY vs. NUMBER OF BIRHTS

Date of delivery: What is your delivery date?

LMP:        last menstrual period: When did you have your last period?

US: ultrasound

Maternity leave from: When did your maternity leave start?

Date of next appointment: When will you have

Examination Dates: When was your last examination? / What is your last examination´s date?

Gynecologist´s signature:


2.

Anamnesis/Medical History


Family history: Are there/Have there been any diseases in your family?

Personal history: Have you had/suffered any diseases in your life?

Operations: Have you had any operations?

Medications: Do you take any pills / medication regularly?

Allergies: Are you allergic to anything?

Blood transfusion: Have you ever had blood transfusion?

Gynecological history: Have you had any gynecological diseases/problems

Menstruation: How is you cycle? How is your period? Regular? Strong/Weak? Etc.

Menstrual cycle from: When did you get your period for the first time?        years          Cycle:
Is the cycle regular?

Abortion:   Have you ever had an abortion?

spontaneous               Have you ever suffered miscarriage?

Gynecological diseases:

Other diseases:

Previous pregnancies: Did you have any problems during your previous pregnancies? Can you describe
your previous pregnancies?

CAVEAT: Is there anything we must be careful about? Do you take any medication? Allergies?


Year

    Birth, Miscarriage, Abortion


                                week of pregnancy

                                                 weight /length

                                                               Spontaneous birth

                                                               Operation complications













3.

Laboratory examination


Blood group and Rh mother: What is your blood group?/blood type?

Blood group and Rh father:

Blood count + “trombo”:                           Date:                           Value:

Antibodies:

O´Sullivan

O GTT

Urine:

OGTT:

Microbiology: GBS - Group B Streptococcus - SAG - Streptococcus agalactiae

Serology: Syphylis, Hepatitis B – C, HIV

Fenylketonuria

Others:


Obstetric examination:

Height:         cm,          Weight before pregnancy:          kg,       Dimensions of pelvis:


Date


Week


Weight


Edema

KBG (?)

Urine


Fetal heart sounds


Blood pressure


High fundus


fetal position


Cervix score - CS


Vaginal examination (cervix, colpo, cyto)





























































































































































Ultrasound examination:

Date                     Week                (12 -14) I screening

Date                     Week                (18 -20) II screening

Date                     Week                (30 – 32) III screening


Cytology             Date            Finding

Colposcopy         Date            Finding

Triple test            Date            Finding

Amniocentesis

Other:


Examination of family doctor:


Stomatology:


Genetic examination:


5.

Other examinations:

Hospitalization: Have you ever been hospitalized? For what reason/why?