Adolescent Prenatal Care Checklist Form
Complete this checklist to support comprehensive prenatal care for adolescent patients. Please answer all questions as accurately as possible.
Patient Full Name
*
First Name
Last Name
Patient Age
*
Estimated Due Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pregnancy Status
*
First pregnancy (primigravida)
Previous pregnancies (multigravida)
Unknown/Unsure
Relevant Prenatal History (e.g., previous complications, medical conditions)
Current Symptoms or Concerns
*
Nausea or vomiting
Abdominal pain or cramping
Vaginal bleeding
Headaches
Swelling (hands, feet, face)
No current symptoms
Other
Current Medications or Supplements
Lifestyle Factors
*
Balanced diet
Physical activity
Tobacco use
Alcohol use
Drug use
None of the above
Other
Support Needs
Emotional support
Nutritional guidance
Transportation assistance
Childcare resources
None at this time
Other
Next Appointment or Follow-up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Checklist
Should be Empty: