OB Patient Form

Array
(
    [USER_NAME] => Gary
)

OB Patient Form

OB Patient Form — Patient ID:

Complete at First Visit

	Test	Result
	Tsh	NL ABN
	Hgb Electrophoresis	NL ABN
	Hep Bsag	NEG POS
	Hep C Ab	NEG POS
	Rubella	IMM NONIMM Equivocal
	Blood Group	A B AB O
	Rh Factor	POS NEG
	Coombs	NEG POS
	Rpr	NEG POS
	Hiv	NEG POS
	Hgb	NL ABN
	Mcv	NL ABN
	Mch	NL ABN
	Platelets	NL ABN
	Urine Culture	NEG POS
	Pap	NL ABN NA
	Gonorrhea	NEG POS
	Chlamydia	NEG POS
	Accept Blood	YES NO

Consents Signed at First Visit

	Test	Result
	Consent Genetics	YES NO
	Consent Dna	YES NO
	Consent Aneuploidy	YES NO
	Consent Vbac	YES NO
	Consent Mbchc	YES NO
	Consent Hiv Ppd	YES NO
	Consent Nica	YES NO
	Consent Lead	YES NO

Complete at Less Than 24 Weeks

	Test	Result
	Aneuploidy Typing	NL ABN NA
	Afp4 Afp	NL ABN NA
	Dates Confirmed	YES NO NA
	Nipt	NL ABN NA
	Amnio Cvs	NL ABN NA
	Amnio Afp	NL ABN NA

DNA Tests Ordered

	Test	Result
	Dna Cystic Fibrosis	NEG POS NA
	Dna Sma	NEG POS NA
	Dna Fragile X	NEG POS NA
	Dna Nieman Pick	NEG POS NA
	Dna Gaucher	NEG POS NA
	Dna Bloom	NEG POS NA
	Dna Fanconi Anemia	NEG POS NA
	Dna Mliv	NEG POS NA
	Dna Alpha Thal	NEG POS NA
	Dna Beta Thal	NEG POS NA
	Dna Canavan	NEG POS NA
	Dna Familial Dysautonomia	NEG POS NA
	Dna Tay Sachs Dna	NEG POS NA
	Dna Tay Sachs Enz	NEG POS NA

Complete at 24 to 28 Weeks

	Test	Result
	W24 Hgb	NL ABN
	W24 Mcv	NL ABN
	W24 Platelets	NL ABN
	W24 1hr Gtt	NL ABN
	W24 3hr Gtt	NL ABN NA
	W24 Rhogam Indicated	YES NO
	W24 Ab Screen Date
	W24 Rhogam Given	YES NO
	W24 Tubal Consent Signed
	W24 Tubal Consent Given Pt

Complete at 28 Weeks to Term

	Test	Result
	W28 Rpr	NEG POS
	W28 Hep Bsag	NEG POS
	W28 Hiv Consent	NEG POS
	W36 Gbs	NEG POS
	W28 Gonorrhea	NEG POS NA
	W28 Chlamydia	NEG POS NA
	W28 Chart Given Date
	W28 Iol Cs Date
	W28 Delivery Location

Additional Labs

	Test	Result
	Fob Hgb Elect	NL ABN Refused
	Fob Hgb	NL ABN Refused
	Fob Mcv	NL ABN Refused
	Fob Mch	NL ABN Refused
	Fob Alpha Thal	NL ABN Refused
	Mob 24 Protein	NL ABN
	Mob Creat Cl	NL ABN
	Mob Cmp	NL ABN
	Mob Alpha Thal	NL ABN
	Mob Anemia Profile	NL ABN
	Urine Cs	NL ABN
	Hrhpv	NEG POS
	Early 1hr Gtt	NL ABN

Behavioral Health Screening

	Test	Result
	Phq9 Depression	NL ABN
	Phq9 Referred	YES NO
	Sbirt Drug	NL ABN
	Sbirt Referred	YES NO

Vaccines

	Test	Result
	Vaccine Influenza	Ordered Given Refused
	Vaccine Influenza Date
	Vaccine Tdap	Ordered Given Refused
	Vaccine Tdap Date
	Vaccine Covid	Ordered Given Refused
	Vaccine Covid Date

Referrals

	Test	Result
	Ref Us Dating	YES NO
	Ref Aneuploidy	YES NO
	Ref Us Nt	YES NO
	Ref Us Anatomy	YES NO
	Ref Genetics	YES NO
	Ref Healthy Start	YES NO
	Ref Dental	YES NO

OB Risk Factors

	Test	Result
	Ob Risk Factors

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