Eclampsia Diagnostic Evaluation Form
Complete this form to assess clinical features relevant to possible eclampsia. Please fill out all sections carefully.
Patient Initials
*
Date and Time of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Gestational Age (weeks)
*
Presenting Symptoms
*
Headache
Visual disturbances
Seizures
Epigastric pain
Altered mental status
Other
Systolic Blood Pressure (mmHg)
*
Diastolic Blood Pressure (mmHg)
*
History of Preeclampsia or Hypertension
*
Yes
No
Unknown
Current Medications
Urine Findings
*
Proteinuria present
No proteinuria
Not assessed
Clinician Notes
Submit Evaluation
Should be Empty: