Little Sisters and Daughters Health Care Provider Form - PowerPoint PPT Presentation

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Little Sisters and Daughters Health Care Provider Form

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How has your older sister's pregnancy and parenting experience been? ... Own Apartment/house Foster Home PARents Group Home With RELatives In a Shelter ... – PowerPoint PPT presentation

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Title: Little Sisters and Daughters Health Care Provider Form


1
Little Sisters and Daughters Health Care Provider
Form
Name ___________________________________
Date __________________________ Phone
______________________ Chief complaint
____________________________ Provider
__________________________ LMP
_____/_____/_____ How has your older sisters
pregnancy and parenting experience been? 0.
Easier and more fun than expected
1. About what I expected 2. Harder and
more stressful then expected 3. N/A Where
living? Own Apartment/house Foster
Home PARents Group Home
With RELatives In a Shelter
With BoyFriend's Relatives
In Jail/detention center With Friends
Other_________________ In school?
0. No Yes, at ________________
Grad/GED Highest grade
completed _____ School goals 0. Dont
know 1. No further 2. GED 3. HS
grad 4. Trade school 5. College
6. gt College Working? 0. No Yes,
_________________(job) _______ hrs/wk
Career goals ____________________ Have BF?
No, Yes, his name is
_____________________ he is ____________ years
old How long with? __________________ Relationsh
ip with BF? 0.None/not seeing
1.Friends 2.Dating 3.Going steady
4.Live together 5.Married
6.Divorced Menarche? __________
Started having sex? Yes No Sexarche
_____ Sex freq? 0. None 1. lt 1/month
2. 1/month 3. 1/wk 4.
Daily BC type ____________ BC use freq?
0. None 1. Some 2. Most 3.
All 4. N/A BC used _at_ last sex? No
Yes N/A BC problems Side effects?______________
______ Cant afford Other problems?
_______________________________________ times
EC used in last 2 months __________ Wants to
have 1st baby? _______ years, or never (99),
or DK Why then? ________________________________
BF-wants a baby? _______years, or never (99)
or DK STD in the last 6 months?
_______________date___________ Abnormal pap
ever? ________________________date______________
How true is it that you think it would be BAD to
get pregnant now. Very true Sort of true
Not very true Not at all true How
true is it that you would NOT like to get
pregnant now. Very true Sort of true
Not very true Not at all true
(Not at
all) (Most important)
(Not at all)
(Most important) How important to NOT be Pg? 4
3 2 1
How important to BF? 4 3
2 1 Whats more important?
______________________________DK Whats
more important to BF? __________________________DK

Weight ______________ Labs ___________________
________________________
Medications Procedures
Other Rx
Referrals Appt. Scheduled ___________
_____________ ________________________
_________________________ ____________________
___________________ ________________________
________________________ ______________________
___ ____________________ ___________________
Other problems Cigarettes Drugs
ETOH Violence Other
___________________________________ Diagnosis
___________________________ Notes
2
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