Personal tools
Navigation
 

OB intake form

Updated April 2013

HTML icon InitialOBConsult.html — HTML, 19 kB (20323 bytes)

File contents

<html>
<title>Initial Obstetrical Consult</title>
<head>

<!--- Created April 2013, Written for version 12.0, No Image, Uses "eform magic" to write to encounter, pushes and pulls measurements for use in other areas, uses check boxes to write in to text spaces --->


<!-------Script to maximize window on loading----------->
<script language="JavaScript1.2">
<!--
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){
top.window.outerHeight = screen.availHeight;
top.window.outerWidth = screen.availWidth;
}
}
//-->
</script>
<!----------End maximizing window scipt---------->
<style type="text/css">
.title{
	text-transform: uppercase;
	font-size: 16;
	font-family: Arial;
	font-weight: bolder;
	text-align: left;
	color: black;
}
.heading1{
	text-transform: capitalize;
	width: 100%;
	font-size: 14;
	font-family: Arial;
	font-weight: bold;
	text-align: left;
	vertical-align: top;
	color: white;
	background-color: black;
	border-width: 1;
}
.heading2{
	text-transform: capitalize;
	width:25%;
	font-size: 12;
	font-family: Arial;
	font-weight: bold;
	text-align: left;
	vertical-align: top;
	color: black;
	background-color: rgb(192,192,192);
	border-width: 1;
}
.normaltext{
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: left;
	vertical-align: top;
	color: black;
	background-color: white;
	border-width: 0;
}
.formtext{
	width: 100%;
	height: 100%;
	font-size: 12;
	font-family: Arial;
	font-weight: normal;
	text-align: left;
	vertical-align: top;
	color: black;
	background-color: white;
	border-width: 1;
	border-style: solid; 
}
</style>

<!-- CSS Script that removes textarea and textbox borders when printing ---(put this inbetween <header></header>)----------------->
<style type="text/css" media="print">
td.subjectline {
	display: none;
}
input.noborder {
	border : 0px;
	background: transparent;
}
textarea.noborder {
	scrollbar-3dlight-color: transparent;
	scrollbar-3dlight-color: transparent;
	scrollbar-arrow-color: transparent;
	scrollbar-base-color: transparent;
	scrollbar-darkshadow-color: transparent;
	scrollbar-face-color: transparent;
	scrollbar-highlight-color: transparent;
	scrollbar-shadow-color: transparent;
	scrollbar-track-color: transparent;
	background: transparent;
	overflow: hidden;
	//scrollbar : none;
	border : 0px;
}
</style>


<!-- ----------------------------------------------------------------------------------------- -->

<script language="javascript">
 function start(){
    if (document.getElementById("counter").value ==''){
       (document.getElementById("counter").value = 1);

	var history1 = document.getElementById('history1').value;
        var history1Split = history1.split("]]-----\n");
        var History1 = history1Split.pop();
        document.getElementById('Current').value = History1;

	var history2 = document.getElementById('history2').value;
        var history2Split = history2.split("]]-----\n");
        var History2 = history2Split.pop();
        document.getElementById('MedicalHistory').value = History2;

	var history3 = document.getElementById('history3').value;
        var history3Split = history3.split("]]-----\n");
        var History3 = history3Split.pop();
        document.getElementById('SocialFamilyHistory').value = History3;

   }
}
</script>

</head>
<body onload = 'start();'>


<form method="post" action="" name="FormName">

<!-- ---------------------------Hidden inputs   ------ -->
<input type="hidden" name="history1" id="history1"  oscarDB=OngoingConcerns>
<input type="hidden" name="history2" id="history2"  oscarDB=Medical_History>
<input type="hidden" name="history3" id="history3"  oscarDB=Other_Medications_History>
<input class="nodisplay" type="hidden" name="counter" id = "counter" >
<input type="hidden" name="date" id="date"  oscardb=today >
<!-- ---------------------- -->


<p class="title">
	Initial Obstetrical Consult
</p>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">OB/GYN History</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2">
			Age<input name="age" type="text" class="formtext" style="width:20;" oscarDB=age>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			G<input name="m$G#value" type="text" class="formtext" style="width:20;" oscarDB=m$G#value>
			P<input name="m$P#value" type="text" class="formtext" style="width:20;" oscarDB=m$P#value>
			T<input name="m$TERM#value" type="text" class="formtext" style="width:20;" oscarDB=m$TERM#value>
			A<input name="A" type="text" class="formtext" style="width:20;">
			(SA<input name="m$SA#value" type="text" class="formtext" style="width:20;" oscarDB=m$SA#value>
			TA<input name="m$TOP#value" type="text" class="formtext" style="width:20;"oscarDB=m$TOP#value>)
			L<input name="m$LIVE#value" type="text" class="formtext" style="width:20;"oscarDB=m$LIVE#value>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			LNMP(YYYY-MM-DD)<input name="m$LMP#value" type="text" class="formtext" style="width:100;"oscarDB=m$LMP#value>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			EDC(YYYY-MM-DD)<input name="m$EDC#value" type="text" class="formtext" style="width:100;"oscarDB=m$EDC#value>
		</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2">
			US<input name="USdates" type="text" class="formtext" style="width:50;" > (=Dates / <>Dates) &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			EGA<input name="m$EGA#value" type="text" class="formtext" style="width:50;" oscarDB=m$EGA#value> (wks+days)
        </tr>
	<tr>
		<td class="heading2">Blood type</td>
		<td><input name="BloodType" class="formtext" type="text"></td>
	</tr>
	<tr>
		<td class="heading2">Problems in Pregnancy</td>
		<td class="normaltext"><textarea name="Current" id="Current" class="formtext" style="height:50;"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Calcium & Vitamin D</td>
		<td><input name="CalciumVitD" class="formtext" type="text"></td>
	</tr>
</table>


<table width="800">
	<tr>
		<td class="heading2">Chief Complaint</td>
		<td class="normaltext"><input class="formtext" name="m$CC#value" id="CC" type="text" oscarDB=m$CC#value onblur="subject.value=CC.value";></td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">History of Present Illness </td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="m$HPI#value" class="formtext" style="height: 200;" wrap="virtual" oscarDB=m$HPI#value></textarea></td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Past History</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="MedicalHistory" id="MedicalHistory"  class="formtext" style="height: 200;" wrap="virtual"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Anesthetic Problems</td>
		<td><textarea name="AnestheticProblems" class="formtext" style="height:20;"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Transfusions?</td>
		<td><textarea name="m$TRAN#value" class="formtext" style="height:20;"oscarDB=m$TRAN#value></textarea></td><td>Yes/No</td>
	</tr>
	<tr>
		<td class="heading2">Sleep Apnea?</td>
		<td><textarea name="m$SLAP#value" class="formtext" style="height:20;"oscarDB=m$SLAP#value></textarea></td><td>Yes/No</td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Medications</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="druglist_generic"  class="formtext" style="height: 200;" wrap="virtual"  oscarDB=druglist_generic ></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Allergies</td>
		<td><textarea name="Allergies" class="formtext" style="height:20;" oscarDB=allergies_des_no_archived></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Latex Allergy?</td>
		<td><textarea name="m$LATX#value" class="formtext" style="height:20;"oscarDB=m$LATX#value></textarea></td><td>Yes/No</td>
	</tr>
	<tr>
		<td class="heading2">Adverse Reactions</td>
		<td><textarea name="AdverseReactions" class="formtext" style="height:20;"></textarea></td>
	</tr>

</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Family History</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="Mom" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Mother-'">Mom
			<input name="Dad" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Father-'">Dad
			<input name="Wife" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Wife-'">Wife
			<input name="Husband" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Husband-'">Husband
			<input name="Son" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Son-'">Son
			<input name="Daughter" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Daughter-'">Daughter
			<input name="Sister" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Sister-'">Sis
			<input name="Broher" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Brother-'">Bro
			<input name="Aunt" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Aunt-'">Aunt
			<input name="Uncle" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Uncle-'">Uncle
			<input name="Grandmother" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Grandmother-'">Grandma
			<input name="Grandfather" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Grandfather-'">Grandpa
			<br>
		</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="BP" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='High Blood Pressure, '">BP
			<input name="CVA" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Cerebral Vascular Accidents, '">CVA
			<input name="MI" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Myocardial Infarction, '">MI
			<input name="Lipid" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Hyperlipidemia, '">Lipid
			<input name="DM" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Diabetes, '">DM
			<input name="Thyr" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Thyroid Disease, '">Thyr
			<input name="Ca" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Cancer, '">Ca
			<input name="BreastCa" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Breast Cancer, '">Breast Ca
			<input name="Glauc" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Glaucoma, '">Glauc
			<input name="GI" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Gastrointestinal Problems, '">GI
			<input name="GU" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='GenitoUrinary Problems, '">GU
			<input name="MSK" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='MusculoSkeletal Problems, '">MSK
			<input name="Resp" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Respiratory Illness, '">Resp
			<input name="Allegy" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Allergies, '">Allergy
			<input name="EtOH" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Alcohol Abuse, '">EtOH
			<input name="Psych" type="checkbox" onclick="document.getElementById('SocialFamilyHistory').value+='Psychiatric Illness, '">Psych
			<br>
			<textarea name="SocialFamilyHistory" id="SocialFamilyHistory" class="formtext" style="height:100;"></textarea>
		</td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Lifestyle</td>
	</tr>
	<tr>
		<td class="heading2">Smoking</td>
		<td class="normaltext">
			<input name="m$SKST#value" type="text" class="formtext" style="width:50;" oscarDB=m$SKST#value> (YES/No)
			<input name="NeverSmoked" type="checkbox" >Never
			<input name="Quit" type="checkbox" >Quit
			<input name="OccasionalSmoke" type="checkbox" >Occ
			<input name="OccasionalSmoke" type="checkbox" >Now
			<input name="m$NOSK#value" type="text" class="formtext" style="width:30px;height:20px;" oscarDB=m$NOSK#value>/day
			&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Start:<input name="StartSmoke" type="text" class="formtext" style="width:50px; height:20px;">
			&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Quit:<input name="QuitSmoke" type="text" class="formtext" style="width:50px; height:20px;">
		</td>
	</tr>
	<tr>
		<td class="heading2">Caffeine</td>
		<td class="normaltext">
			<input name="Caffeine" type="text" class="formtext" style="width:100;">/day
		</td>
	</tr>
	<tr>
		<td class="heading2">Alcohol</td>
		<td class="normaltext">
			<input name="m$ALC#value" type="text" class="formtext" style="width:50;" oscarDB=m$ALC#value> (YES/No)
			<input name="m$DRPW#value" type="text" class="formtext" style="width:50;" oscarDB=m$DRPW#value> /wk
		</td>
	</tr>
	<tr>
		<td class="heading2">Drugs</td>
		<td class="normaltext">
			<input name="IVDU" type="checkbox" onclick="document.getElementById('Drugs').value+='IV Drug Use, '">IVDU
			<input name="Drugs" id="Drugs" type="text" class="formtext" style="width:500;">
		</td>
	</tr>
	<tr>
		<td class="heading2">Diet</td>
		<td class="normaltext"><input name="Diet" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Fitness</td>
		<td class="normaltext"><input name="Fitness" type="text" class="formtext"></td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1" colspan="2">Social History</td>
	</tr>
	<tr>
		<td class="heading2">Relationship Status</td>
		<td class="normaltext">
			<input name="Single" type="checkbox">Single
			<input name="Married" type="checkbox">Married
			<input name="CommonLaw" type="checkbox">Common Law
			<input name="Separated" type="checkbox">Separated
			<input name="Divorced" type="checkbox">Divorced
			<input name="Widowed" type="checkbox">Widowed
		</td>
	</tr>
	<tr> 
		<td class="heading2">Partner's Name</td>
		<td class="normaltext"><input name="PartnerName" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Sexual Partners</td>
		<td class="normaltext">
			<input name="PartnerM" type="checkbox">M 
			<input name="PartnerF" type="checkbox">F 
			<input name="PartnerBoth" type="checkbox">Both 
			<input name="PartnerNone" type="checkbox">None 
		</td>
	</tr>
	<tr>
		<td class="heading2">Sexual Concern</td>
		<td class="normaltext">
			<input name="SexualConcerns" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Assault/Abuse</td>
		<td class="normaltext">
			<input name="m$ASLT#value" type="text" class="formtext" style="width:50;" oscarDB=m$ASLT#value>
		</td>
	</tr>
	<tr>
		<td class="heading2">Counseling?</td>
		<td class="normaltext">
			<input name="Counseling" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Education</td>
		<td class="normaltext">
			<input name="Education" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Occupation</td>
		<td class="normaltext">
			<input name="Occupation" id="Occupation" type="text" class="formtext">
		</td>
	</tr>
</table>



<table width="800">
	<tr>
		<td class="heading1" colspan="2">Examination</td>
	</tr>
	<tr class="heading2">
		<td class="heading2">Measurements</td>
		<td class="normaltext">
			HT<input name="m$HT#value" type="text" class="formtext" style="width:50;" oscarDB=m$HT#value> (cm)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			WT<input name="m$WT#value" type="text" class="formtext" style="width:50;" oscarDB=m$WT#value> (kg)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			BMI<input name="m$BMI#value" type="text" class="formtext" style="width:50;" oscarDB=m$BMI#value> (kg/m<sup>2</sup>)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			BP<input name="m$BP#value" type="text" class="formtext" style="width:50;" oscarDB=m$BP#value> (sitting) &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
		</td>
	</tr>
	<tr class="heading2">
		<td class="heading2">Routine Exam</td>
		<td class="normaltext">
					<table width="100%">
						<tr><td class="normaltext"> H&N <input name="m$HN#value" type="text" class="formtext" style="width:50;" oscarDB=m$HN#value> (N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
						Chest<input name="m$CHST#value" type="text" class="formtext" style="width:50;" oscarDB=m$CHST#value>(N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
						CVS<input name="m$CVS#value" type="text" class="formtext" style="width:50;" oscarDB=m$CVS#value>(N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
						Abd<input name="m$ABD#value" type="text" class="formtext" style="width:50;" oscarDB=m$ABD#value>(N/Abn)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td></tr>
						<tr><td class="normaltext">Pelvic<input name="m$PELV#value" type="text" class="formtext" style="width:75%;" oscarDB=m$PELV#value>(N/Abn/Disc)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td></tr>
					</table>	
		</td>
</tr>

	<tr class="heading2">
		<td class="heading2">OB Measurements</td>
		<td class="normaltext">
			SFH<input name="m$SFH#value" type="text" class="formtext" style="width:50;" oscarDB=m$SFH#value> (cm)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			FHR<input name="m$FHR#value" type="text" class="formtext" style="width:50;" oscarDB=m$FHR#value> (BPM)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
		</td>
	</tr>

</table>
<table width="800">
	<tr>
		<td class="heading1"  colspan="2">Assessment:</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="m$SES#value" class="formtext" style="height:100;"></textarea></td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1"  colspan="2">Plan:</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="m$PLAN#value" class="formtext" style="height:100;"></textarea></td>
	</tr>
</table>


<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div name="FunctionButtons" class="DoNotPrint">
<table>
<tr>
	<td class="subjectline">
		Subject: <input name="subject" size="40" type="text" oscarDB=m$CC#value>
		<input value="Submit" name="SubmitButton" type="submit">
		<input value="Reset" name="ResetButton" type="reset">
		<input value="Print" name="PrintButton" onclick="javascript:window.print()" type="button">
	</td>
</tr>
</table>
</div>

</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->


</body>
</html>
<!--
<template>
 <encounternote>
 $t{age} yo G $t{m$G#value} P $t{m$P#value} SA $t{m$SA#value} TOP $t{m$TOP#value}
 
 LNMP: $t{m$LMP#value}, EDC $t{m$EDC#value}, U/S $t{USdates}, EGA $t{m$EGA#value}
 
 CC: $t{m$CC#value}
 
 HPI: $t{m$HPI#value}
 

 
 Occupation: $t{Occupation}
 
 PMHx: $t{MedicalHistory}
 
 GA prob? $t{AnestheticProblems}
 
 Trans? $t{m$TRAN#value}
 
 App? $t{m$SLAP#value}
 
 Meds: $t{druglist_generic}
 
 Allergies: $t{Allergies}
 
 Latex: $t{m$LATX#value}
 
 $t{m$NOSK#value} Cigarettes,  $t{m$DRPW#value} Drinks per week , Drugs $t{Drugs}, Abuse $t{m$ASLT#value},Couselling $t{Counseling}
 
 ON EXAMINATION
 
 Ht $t{m$HT#value} cm, Wt  $t{m$WT#value} kg, BMI  $t{m$BMI#value} kg/m2
 BP  $t{m$BP#value}
 H&N  $t{m$HN#value} Chest  $t{m$CHST#value}
 CVS  $t{m$CVS#value} Abd  $t{m$ABD#value}
 SFH $t{m$SFH#value} FHR $t{m$FHR#value}
 Pelvis  $t{m$PELV#value}
 
 Assessment $t{m$SES#value}
 
 Plan $t{m$PLAN#value}
 
 </encounternote>
 <familyhistory> $t{SocialFamilyHistory} </familyhistory>
 <medicalhistory> $t{MedicalHistory} </medicalhistory>
 <ongoingconcerns> $t{Current} </ongoingconcerns>



</template>
-->

Document Actions

 

Download button

DOWNLOAD OSCAR FOR TESTING

 

eForms button

DOWNLOAD SHARED E-FORMS


 Customize button

FIND PLUG-INS AND TWEAKS
FOR YOUR OSCAR EMR

 

Subscribe Button

SUBSCRIBE TO DISCUSSION LIST 
(SEE ALL LISTS)

  

Help button

ACCESS THE ONLINE MANUALS
(PAID SUPPORT)