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Pregnancy Sample Paper Work PDF Details

Are you a pregnant woman who is looking for work? Are you concerned about how your pregnancy might affect your job status? If so, then you should know about the Pregnancy Sample Paper Work Form. This form is a way to communicate with your employer about your pregnancy and upcoming leave. Knowing about the form and what it entails can help ease your mind during this process. Let's take a closer look at the Pregnancy Sample Paper Work Form and what it can do for you.

This quick report will aid you to figure out the time it will require you to fill out pregnancy sample paper work, the number of pages it has, and a few additional unique details about the file.

Question	Answer
Form Name	Pregnancy Sample Paper Work
Form Length	2 pages
Fillable?	Yes
Fillable fields	158
Avg. time to fill out	32 min 10 sec
Other names	positive pregnancy results form, confirmation of pregnancy form, hospital positive pregnancy paperwork, pregnancy paperwork

12

Form Preview Example

PPCT POSITIVE IN PREGNANCY FORM

DATE:_____/______/_____

DD

MM

YYYY

NAME:

PSC Patient ID:

ANTENATAL ID:

SITE:

Date of Birth: _____/____/_____

DD

MM

YYYY

If birth date unknown, age at last birth day: ____ years

SOCIAL/DEMOGRAPHIC HISTORY:

Date of 1st positive HIV test:

฀ Yes

฀ No ฀ N/A

______/______/_________

Has your partner been tested for HIV?

DD

MM

YYYY

What is your occupation?

Do you (or your family) generally have enough money to cover your expenses?

___________________________

฀ Yes

฀No

What is your marital status?

Highest level of education

How many people usually live in your household

฀ Single

฀ None

including yourself? _______

฀ Widowed/single

฀ Some primary

Children under 5 years of age? ______

฀Widowed/married

฀ Some secondary

Children between 5 and 14 years of age______

Individuals that are 15 years of age

฀ Married/living together

฀ Some college/university

or older? ________

male, number of wives_______

female, number of co-wives_____

DISCLOSURE

Have you disclosed your HIV status to anyone?

฀ Yes

฀No

To whom?

฀ Partner/spouse

฀Friend

฀Relative

฀ Other (specify): ______________________

OBSTETRIC HISTORY

Enter number of:

Total pregnancies ______

Live births ____________

LMP _______/_______/_________

EDD: _______/_______/_______

Miscarriages___________

DD

MM

YYYY

DD

MM

YYYY

Currently living_________

How many months are you

REFER TO MOH MOTHERS HEALTH CARD

(if none-> mark 0)

currently pregnant? ________

FOR ANATENAL CARE

PAST MEDICAL AND SURGICAL HISTORY

฀ Diabetes

฀Hypertension ฀PreEclampsia/Toxemia

฀Cesarean ฀4th degree Laceration/fistula

Other:___________________________________________________________________________________________________

_______________________________________________________________________________________________


					Has the patient been treated for TB before?		฀Yes	฀No	If yes, year_______
	TB HISTORY				Is the patient currently being treated for TB?			฀Yes	฀No
	TB HISTORY				Any household member previously/currently treated for TB?			฀Yes	฀No
					Any household member previously/currently treated for TB?			฀Yes	฀No
	PHYSICAL EXAMINATION
	VITALS				EXAMINATION	COMMENTS/DESCRIPTION
					Eyes, Ears, Nose, Throat

	Temp: ______ o C				Lymph Nodes
	Temp: ______ o C
	Pulse:	______ b/min			Respiratory

					Cardiovascular
					Cardiovascular
	BP:	___/___ mmHg
	BP:	___/___ mmHg			Gastrointestinal
					Gastrointestinal
	Weight:______Kg
	Weight:______Kg				Neurological

	Height: ______cm				Musculoskeletal

	Resp. rate:__________				Genitourinary
	Resp. rate:__________
		breaths/min			Skin

					Other
					Other

1

WHO ADULT HIV STAGING SYSTEM

WHO ADULT STAGE 1

□ Asymptomatic HIV Infection	□ Persistent Generalized Lymphadenopathy (PGL)

WHO ADULT STAGE 2

□	Moderate weight loss (<10% of presumed or measured body	□	Herpes Zoster past or recurrent within last 2 years
□	weight)	□	Recurrent or chronic upper respiratory tract infections
□	Minor mucocutaneous manifestations (seborrheic dermatitis,		(bacterial sinusitis, bronchitis, otitis media pharyngitis)
	prurigo, fungal infection, recurrent oral ulcerations, angular
	cheilitis

WHO ADULT STAGE 3

□	Severe weight loss (> 10% of presumed or measured body weight)	□ Oral hairy leukoplakia (OHL)
□ Unexplained chronic diarrhea > 1 month		□	Pulmonary tuberculosis (PTB) in last year
□ Unexplained prolonged fever > 1 month		□	Severe bacterial infections (e.g. pneumonia,
□	Oral candidiasis (Thrush)		pyomyositis, empyema, bone or joints infections)

WHO ADULT STAGE 4

□ HIV wasting syndrome (Severe weight loss and either unexplained

□

Isosporiasis

□

chronic diarrhea or unexplained prolonged fever > 1 month)

□

Disseminated non-tuberculous mycobacterial

Pneumocystis carinii pneumonia

infection

□ Recurrent severe bacterial pneumonia (>/=2 episodes within 1

□

Cytomegalovirus (CMV) retinitis or disease of the

year)

□

Progressive multifocal leukoencephalopathy (PML)

□

Cryptococcal meningitis, cryptococcosis

□

Any disseminated endemic mycosis (e.g.

□ Toxoplasmosis of the brain

histoplasmosis)

□ Chronic orolabial, genital or ano-rectal herpes simplex virus

□

Candidiasis of the oesophagus or airways

infection > 1 month

□

Non-typhoid salmonella (NTS) septicaemia

□

Kaposi’s sarcoma

□

Primary CNS lymphoma or B cell NHL

□

HIV encephalopathy

□ Extra pulmonary tuberculosis (EPTB)

□ Cryptosporidiosis with diarrhea > 1 month

Based on history and physical examination, indicate the most advanced WHO stage: O 1

O 2

O 3

O 4

INVESTIGATIONS ORDERED TODAY

฀ HB

฀UA

฀Blood group/RH

฀MPS

฀ VDRL

฀ CD4

MEDICATIONS PRESCRIBED TODAY

ARVS: ฀NVP ฀AZT

฀Other ARVS ______, ______, ______, ______

O Multivitamin

O CTX

O Food by prescription

O Iron/folate

O Albendazole

O Anti TB medications ______,

______,

O TT

O Malaria IPT

______, _______

	WHAT REFERRALS WILL BE MADE FOR THE PATIENT?

	฀None			฀TB treatment/DOT program						฀ PSC for HIV care
	฀Social Support groups			฀Nutritional services						฀Inpatient care/Hospitalization
	฀Other referral, specify:________________
	Follow up issues for next visit:

						Form completed by:
	Next Scheduled Appointment Date					CCHA______________________________
	Next Scheduled Appointment Date
	______ / ______ / ________					Nurse				________
	DD	MM	YYYY			Clinical Officer
						Medical Officer

2

How to Edit Pregnancy Sample Paper Work Online for Free

The positive pregnancy paperwork completing process is very simple. Our editor lets you work with any PDF document.

Step 1: The initial step should be to click on the orange "Get Form Now" button.

Step 2: At the time you access our positive pregnancy paperwork editing page, you will find all the actions you can take regarding your template at the upper menu.

These sections will make up your PDF form:

step 1 to writing proof of pregnancy form from doctor

Type in the necessary details in the area TB, HISTORY PHYSICAL, EXAMINATION, VITALS EXAMINATION, COMMENTS, DESCRIPTION Eyes, Ears, Nose, Throat Tempo, C Pulse, bm, in mmHg, Weight, Kg Height, cm Lymph, Nodes Respiratory, Cardiovascular, Gastrointestinal, and Neurological.

stage 2 to finishing proof of pregnancy form from doctor

Provide the necessary details in the Height, cm Resp, rate breaths, min Mus, cul, o, skeletal Genitourinary, Skin, and Other field.

proof of pregnancy form from doctor Heightcm, Resprate, breathsmin, Musculoskeletal, Genitourinary, Skin, and Other blanks to insert

You have to define the rights and obligations of all parties in box WHO, ADULT, STAGE A, symptomatic, HIV, Infection WHO, ADULT, STAGE WHO, ADULT, STAGE WHO, ADULT, STAGE infection, month infection, Iso, spor, i, as, is Primary, CNS, lymphoma, orB, cell, NHL and his, to, plasm, os, is

Completing proof of pregnancy form from doctor stage 4

Finish by reviewing the next sections and filling them in as required: OOO, U, AMPS, CD OCT, XO, Alben, daz, oleO, Malaria, IP, T None, TB, treatment, DOT, program and PS, C, for, HIV, care

Finishing proof of pregnancy form from doctor step 5

Step 3: After you have hit the Done button, your file should be readily available transfer to any kind of gadget or email address you identify.

Step 4: Be sure to make as many copies of your document as you can to stay away from potential issues.

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