Maternal-Fetal Medicine Consultation

Patient Information

Name Date of Birth Medical Record Number

Consultation Date

Obstetric History

Gravida Para Gestational Age Last Menstrual Period Estimated Due Date

Indication for Consultation

Relevant Medical History

Current Pregnancy Details

Complications Medications

Physical Exam Findings

Ultrasound/Fetal Assessment

Laboratory/Diagnostic Studies

Assessment & Plan

Recommendations

Follow-Up