Age: ________ LMP: ____/____/____ G___ T___ P___ A___/___ L___ Current BCM: ______________________

PPMPF 149 Page 1 of 2 Rev: 1/2014

Pregnancy Test Visit

Reason for today’s visit: ________________________________________________________ Age: ______

Do you have any allergies?  Yes  No Are you allergic to: 

la te x  me dica tion (

___________________

What was the first day of your last menstrual period? Date: ___________

Was it normal (timing, amount of bleeding)?  Ye s  No

My last period was:  On time  E a rly  La te

The amount of bleeding was:

 Norma l

 Lighter

 Heavier

Does your period come every month?  Yes  No

Do you have any problems with your period?  Yes  No If yes, what?

___________________________________

Have you ever had a PAP test? Date: _____________ Was it normal?  Yes  No  Unsure

Do you protect yourself from pregnancy?

 Ye s

 No

If yes, how? _______________________

Date of last sex without a birth control method: _________________

Yes

Are your menstrual cycles usually monthly?

Were you using a method of birth control when you think you may have become pregnant?

Have you taken a home pregnancy test? If yes, when? ___________ Result: _______________

Do you want to be pregnant?

 Undecided

 In the future

Have you been pregnant before? If yes, # of live births ______ # of abortions ______

# of miscarriages ______ # of tubal pregnancies ______ # of still births ______

If your pregnancy test is negative, would you be interested in starting on birth control? *

 Undecided  Already on birth control ______________

Since your last period have you had any bleeding or spotting? **

Have you ever had pelvic inflammatory disease (not yeast, not bacterial vaginosis)? **

Since your last period, have you had any one-sided abdominal pain? **

Have you had a ruptured appendix? **

Have you had a tubal ligation (tubes tied) or any other surgery on your tubes? **

Have you ever had Lupus?

Have you had any other serious illness or surgery?

Yes No

Are you under 18 years old and are your parent(s)/guardian(s) aware of your visit to Planned

Parenthood of Maryland?

CLIENT SIGNATURE

TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS COMPLETE AND CORRECT.

Client Signature: X_____________________________________________ Date: _______________________

Relationship and Safety

Violence and sexual abuse are common in many people’s lives. There is help for you if you are being hurt or abused.

(Note: PPM is required to report cases of child abuse or neglect that occurred as a minor, even if you are now over age 18.)

NEVER SOMETIMES OFTEN DECLINE

Has your partner ever tried to get you pregnant when you

didn’t want to be?

Does your partner refuse to use condoms when you ask?

Are you afraid your partner will hurt you?

Have you ever been physically or emotionally abused by

your partner or someone important to you?

Have you been hit, slapped kicked or otherwise physically

hurt by someone in the past year or, if you’re pregnant since

you’ve been pregnant?

Has anyone forced you to have sex in the past year?

Client’s Name: _____________________________

DOB: ________________ Date: ________________

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PPMPF 149 Page 2 of 2 Rev: 1/2014

*** Staff Use Only ***

SUBJECTIVE (HPI) – Brief HPI

HCA COMMENTS: ________________________________________________________________________________

________________________________________________________________________________________________

 Hx Re vie we d 

New



Est HCA Signature:_________________________________________ Date:____________

CLINICIAN COMMENTS: ___________________________________________________________________________

________________________________________________________________________________________________

 Hx Re vie we d

Clinician Signature:_________________________________________ Date:_____________________

OBJECTIVE (PE)

BMI

LMP: ____________

UPT: 

 Inconclusive

If positive:

EGA by LMP __________

EGA by

bi-manual __________

EDD __________

 A & O x 3

 NAD

 Apparent distress:

__________

Depo Injection

Lot#

_______________________

Location:_________________

Exp date____________

RTC: __________________

 IM  S UB Q

LABS SENT OUT:



Chlamydia  GC



Other __________________

Rapid HIV:  Ne g

 P re lim P os  Inde te rmin

 De cline s S TI Tes ting

ASSESSMENT



Client desires to continue pregnancy



UPT Negative

 Client desires to terminate pregnancy  Client desires adoption

 Undecided  Risk factors for ectopic pregnancy

PLAN

If pregnancy test was positive:

 All options discussed (continuing the pregnancy, abortion and

adoption) and info given for

 Prenatal care

 Abortion

 Adoption

 Provided info on early prenatal care, including folic acid

 Rx given for prenatal vitamins

 Reviewed signs and symptoms of ectopic pregnancy and

miscarriage

 Birth control information given

 Condoms offered / encouraged

If pregnancy test was negative:

 Advised to repeat UPT in ____________

 Contraception options reviewed, including abstinence

 EC CIIC given **

 BCM (Contra Choices) information given

 Folic acid/prenatal vitamin info given

 Client encouraged to RTC for yearly exams, if appropriate

 HOPE appt offered

 Hope visit done today – see HOPE form

 Condoms use encouraged/offered

 If no unexplained menses x 3 months, advised follow-up

 Preconception counseling

CIICs/CIs provided in language other than English:

 Spanish

Other CIICs/CIs/Education:

 CIIC: Pregnancy Testing, Options Counseling

 CI: Ectopic Pregnancy

 _________________ ** As of current year’s MS&Gs

Clinician Comments:

_____________________________________________________

Other:

 S a fe ty Card Give n

 HPV Vaccine Information Given

 Reproductive Life Plan discussed

 Interpretation provided by PPM

 Interpretation provided by client’s preferred interpreter

(__________________)

Total time spent with clinician: _________

( Spent >50% of the time counseling/education)

Signature:____________________________________

Date:_____________________

If under 18, parental involvement  previously indicated  encouraged

Client’s Name: _____________________________

DOB: ________________ Date: ________________

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