Free Pregnancy Health Record Template
Pregnancy Health Record
Provided by [YOUR NAME] - [YOUR COMPANY NAME]
A. Personal Information
|
Field |
Details |
|---|---|
|
Full Name |
Adrienne Daniel |
|
Date of Birth |
05/14/2058 |
|
Address |
Mobile, AL 36601 |
|
Contact Number |
222 555 7777 |
|
Email Address |
adrienne@you.mail |
|
Emergency Contact Name |
John Daniel |
|
Emergency Contact Phone |
222 555 77777 |
B. Medical History
|
Condition |
Yes/No |
Additional Details |
|---|---|---|
|
Previous Pregnancies |
Yes |
2 previous pregnancies, both normal deliveries |
|
Chronic Conditions (e.g., Diabetes, Hypertension) |
No |
N/A |
|
Allergies |
Yes |
Penicillin |
|
Medications Currently Taking |
Yes |
Prenatal Vitamins, 400mg Folic Acid |
C. Current Pregnancy Information
|
Field |
Details |
|---|---|
|
Expected Due Date |
03/15/2086 |
|
Weeks Gestation (at today’s date) |
22 weeks |
|
Obstetrician/Gynecologist Name |
Dr. Sarah Future |
|
Contact Information |
222 555 7777 |
|
Pregnancy Type (e.g., Single, Twins) |
Single |
|
Planned Hospital or Birthing Center |
Metro General Birthing Unit |
D. Prenatal Check-Up Record
|
Date |
Weight (lbs/kg) |
Blood Pressure (mmHg) |
Fetal Heart Rate (BPM) |
Notes |
|---|---|---|---|---|
|
10/01/2086 |
145 lbs |
120/80 |
150 |
Normal check-up; no concerns |
|
11/01/2086 |
147 lbs |
122/78 |
152 |
Ultrasound scheduled for next visit |
E. Lab Tests & Results
|
Test Name |
Date Conducted |
Results |
Notes |
|---|---|---|---|
|
Blood Test |
09/15/2086 |
Normal |
All levels within range |
|
Urine Test |
09/15/2086 |
Normal |
No signs of infection |
|
Ultrasound |
10/15/2086 |
Normal |
Healthy single fetus |
F. Vaccinations Received During Pregnancy
|
Vaccine Name |
Date Administered |
Additional Notes |
|---|---|---|
|
Influenza |
09/20/2086 |
No adverse reactions |
|
Tdap |
10/15/2086 |
Recommended booster given |
G. Notes & Observations
Patient is in good health with no complications noted at this stage. Fetal development on track. Continue with prenatal vitamins and regular check-ups.
