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ATIONSHIP PRENATAL HISTORY FIRST PRENATAL VISIT DATE ALCOHOL, AMOUNT STDs (specify) HEPATITIS B WEEKS GESTATION ! TOBACCO, AMOUNT OTHER MATERNAL PROBLEMS CAESAREAN WHERE DELIVERED OTHER ! SVD PRESCRIBED MEDS BIRTH WEIGHT HIV STREET DRUGS DATE OF D/C - LOS PERINATAL HISTORY DEFORMITIES/APGAR ABNORMALITIES INTERVAL HISTORY PAST MEDICAL HISTORY WNL YES NO (IF NO, DESCRIBE) DEVELOPMENTAL HISTORY WNL YES NO (IF NO, DESCRIBE) BEHAVIORAL HEALTH STATUS WNL YES.

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