Docstoc

PRENATAL WEIGHT GAIN CHART

Document Sample
PRENATAL WEIGHT GAIN CHART Powered By Docstoc
					 1. Last Name                                              First Name                           MI                     N.C. Department of Health and Human Services
                                                                                                                           Women’s and Children’s Health Section
 2. Patient Number
 3. Date of Birth
    (MM/DD/YYYY)
                                                                                                                PRENATAL WEIGHT GAIN CHART
                                       Month     Day           Year
 4. Race  □ American Indian or Alaska Native  □ Asian
                                                                                                                         Pre-Pregnancy Underweight
          □ Black/African American  □ Native Hawaiian/Other Pacific Islander                                                     BMI <18.5
          □ Unknown  □ White
 5. Ethnic Origin □ Hispanic Cuban      □ Hispanic Mexican American                                             Weight Gain Recommendations (singleton):
                  □ Hispanic Other      □ Hispanic Puerto Rican                                                 ♦  2.2–6.6 lb. gain 1st trimester
                  □ Not Hispanic/Latino □ Unreported                                                            ♦  1 lb. gain per week 2nd and 3rd trimesters
 6. Gender □ Female □ Male
 7. County of Residence                                                                                         ♦  28–40 lb. total weight gain

                                     45
                                              EDC ______________________________
                                              Ht. (without shoes) __________________
                                              Pre-Pregnancy Wt. ___________________
                                     40       Pre-Pregnancy BMI __________________

                                                           Weeks
                                               Date       Gestation       Weight        Notes


                                     35




                                     30




                                     25
              Weight Gain (Pounds)




                                     20




                                     15




                                     10




                                      5




                 baseline




                                     -5
                                          0           4               8            12      16         20              24              28              32              36             40
DHHS 2388 (Revised 06/10)                                                                  Weeks of Gestation
Women’s and Children’s Health Section (Review 06/13)
Source: Institute of Medicine, 2009. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC. National Academies Press; Committee to Reexamine IOM Pregnancy Guidelines.
 1. Last Name                                               First Name                           MI                    N.C. Department of Health and Human Services
                                                                                                                           Women’s and Children’s Health Section
 2. Patient Number
 3. Date of Birth
    (MM/DD/YYYY)
                                                                                                                PRENATAL WEIGHT GAIN CHART
                                       Month     Day           Year
 4. Race  □ American Indian or Alaska Native  □ Asian
                                                                                                                       Pre-Pregnancy Normal Weight
          □ Black/African American  □ Native Hawaiian/Other Pacific Islander                                                   BMI 18.5–24.9
          □ Unknown  □ White
 5. Ethnic Origin □ Hispanic Cuban      □ Hispanic Mexican American                                             Weight Gain Recommendations (singleton):
                  □ Hispanic Other      □ Hispanic Puerto Rican                                                 ♦  2.2–6.6 lb. gain 1st trimester
                  □ Not Hispanic/Latino □ Unreported                                                            ♦  1 lb. gain per week 2nd and 3rd trimesters
 6. Gender □ Female □ Male
 7. County of Residence                                                                                         ♦  25–35 lb. total weight gain

                                      45
                                               EDC ______________________________
                                               Ht. (without shoes) __________________
                                               Pre-Pregnancy Wt. ___________________
                                      40       Pre-Pregnancy BMI __________________

                                                            Weeks
                                                Date       Gestation       Weight        Notes


                                      35




                                      30




                                      25
               Weight Gain (Pounds)




                                      20




                                      15




                                      10




                                       5




                  baseline




                                      -5
                                           0           4               8            12      16         20              24              28             32              36              40
DHHS 2388 (Revised 06/10)                                                                   Weeks of Gestation
Women’s and Children’s Health Section (Review 06/13)
Source: Institute of Medicine, 2009. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC. National Academies Press; Committee to Reexamine IOM Pregnancy Guidelines.
 1. Last Name                                              First Name                           MI                     N.C. Department of Health and Human Services
                                                                                                                           Women’s and Children’s Health Section
 2. Patient Number
 3. Date of Birth
    (MM/DD/YYYY)
                                                                                                                PRENATAL WEIGHT GAIN CHART
                                       Month     Day           Year
 4. Race  □ American Indian or Alaska Native  □ Asian
                                                                                                                           Pre-Pregnancy Overweight
          □ Black/African American  □ Native Hawaiian/Other Pacific Islander                                                     BMI 25.0–29.9
          □ Unknown  □ White
 5. Ethnic Origin □ Hispanic Cuban      □ Hispanic Mexican American                                             Weight Gain Recommendations (singleton):
                  □ Hispanic Other      □ Hispanic Puerto Rican                                                 ♦  2.2–6.6 lb. gain 1st trimester
                  □ Not Hispanic/Latino □ Unreported                                                            ♦  0.6 lb. gain per week 2nd and 3rd trimesters
 6. Gender □ Female □ Male
 7. County of Residence                                                                                         ♦  15–25 lb. total weight gain
                                     45
                                              EDC ______________________________
                                              Ht. (without shoes) __________________
                                              Pre-Pregnancy Wt. ___________________
                                     40       Pre-Pregnancy BMI __________________

                                                           Weeks
                                               Date       Gestation       Weight        Notes


                                     35




                                     30




                                     25
              Weight Gain (Pounds)




                                     20




                                     15




                                     10




                                      5




                    baseline




                                     -5
                                          0           4               8            12      16          20             24              28              32              36              40
DHHS 2388 (Revised 06/10)                                                                  Weeks of Gestation
Women’s and Children’s Health Section (Review 06/13)
Source: Institute of Medicine, 2009. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC. National Academies Press; Committee to Reexamine IOM Pregnancy Guidelines.
 1. Last Name                                               First Name                          MI                     N.C. Department of Health and Human Services
                                                                                                                           Women’s and Children’s Health Section
 2. Patient Number
 3. Date of Birth
    (MM/DD/YYYY)
                                                                                                                PRENATAL WEIGHT GAIN CHART
                                       Month     Day           Year
 4. Race  □ American Indian or Alaska Native  □ Asian
                                                                                                                               Pre-Pregnancy Obese
          □ Black/African American  □ Native Hawaiian/Other Pacific Islander                                                        BMI ≥ 30.0
          □ Unknown  □ White
 5. Ethnic Origin □ Hispanic Cuban      □ Hispanic Mexican American                                             Weight Gain Recommendations (singleton):
                  □ Hispanic Other      □ Hispanic Puerto Rican                                                 ♦  1.1–4.4 lb. gain 1st trimester
                  □ Not Hispanic/Latino □ Unreported                                                            ♦  0.5 lb. gain per week 2nd and 3rd trimesters
 6. Gender □ Female □ Male
 7. County of Residence                                                                                         ♦  11–20 lb. total weight gain
                                     45
                                              EDC ______________________________
                                              Ht. (without shoes) __________________
                                              Pre-Pregnancy Wt. ___________________
                                     40       Pre-Pregnancy BMI __________________

                                                           Weeks
                                               Date       Gestation       Weight        Notes


                                     35




                                     30




                                     25
              Weight Gain (Pounds)




                                     20




                                     15




                                     10




                                      5




                 baseline




                                     -5
                                          0           4               8            12      16         20              24              28              32              36              40
DHHS 2388 (Revised 06/10)                                                                  Weeks of Gestation
Women’s and Children’s Health Section (Review 06/13)
Source: Institute of Medicine, 2009. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC. National Academies Press; Committee to Reexamine IOM Pregnancy Guidelines.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:166
posted:11/3/2011
language:English
pages:4