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.

QuestionAnswer
Form NamePregnancy Sample Paper Work
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespaperwork for pregnancy, proof of pregnancy papers, pregnancy test template, printable positive pregnancy results

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

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

Pulse:

______ b/min

 

Respiratory

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardiovascular

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BP:

___/___ mmHg

 

 

 

 

 

 

 

 

Gastrointestinal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight:______Kg

 

 

 

 

 

 

 

 

Neurological

 

 

 

 

 

 

 

 

 

 

 

 

 

Height: ______cm

 

Musculoskeletal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resp. rate:__________

 

Genitourinary

 

 

 

 

 

 

 

 

 

 

 

 

 

breaths/min

 

Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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______________________________

 

 

 

 

 

 

 

 

 

______ / ______ / ________

 

 

Nurse

 

 

 

________

 

 

DD

MM

YYYY

 

 

Clinical Officer

 

 

 

 

 

 

 

 

 

Medical Officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

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