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Pregnant Woman
Your name: ________________________Baby is due:_____________
At todays visit, we will talk about:
How are you feeling
Healthy eating during pregnancy
Health/medical:
10 11 13 14 15 16 17 18 19
23 32 33 34 35 36 38 39 40
41 43 50 51 52 53 59 60 61
62
Breastfeeding plan
70
Alcohol
54
3 months prior to pregnancy:
_____days _____# drinks
Past month:
_____days _____# drinks
Smoking
55 63
3 months prior to pregnancy:
_____ # cigs per day
Family environment:
90 96 97
56
pregnancy? No
Yes
I would like to find a dentist
Staff use
only: Nutrition
practices:
42 65 66 88
Topics discussed:
Diarrhea
Eating all the
Food cravings
Cravings for things like ice,
soda, clay, or
Are you following a prescribed special diet, weight control diet, vegan or
macrobiotic way of eating?
describe:_____________________________________
Smile
How many times a day do you usually eat? ______ # meals per
day ______ # snacks
per day
How would you describe your appetite? Good
Fair
Poor
Ed materials given:
None
Spangler)
Loving
Support
material
After
You
Deliver
Deliver a Healthy
Referrals:
None
HBKF. Declined
Provider/medical
home
_________________
SMART plan is:
Food package: A
Nutrition follow up/next steps: INCP
28 week recall Phone call Weight check
Clinic or office visit
Invited to group/nutrition activity:
F Omissions:
___________________________
__ Staff signature & title
___________________________
__ Date of visit
Other: