Preeclampsia Admission Checklist Form
Complete this checklist for hospital intake and triage of patients with suspected or confirmed preeclampsia. Please provide accurate information to support prompt and effective care.
Patient Full Name
*
First Name
Last Name
Admission Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Presenting Symptoms
*
Headache
Visual Disturbances
Epigastric Pain
Nausea/Vomiting
Swelling/Edema
Other
Blood Pressure on Admission (mmHg)
*
Proteinuria Status
*
Positive
Negative
Not Assessed
Gestational Age (weeks)
*
Relevant Medical History
Current Medications
Known Allergies
Submit Checklist
Should be Empty: