IPRS Mother's Nutrition-Profile Form - EPNM-Pro

CLIENT PROFILE AND MEDICAL HISTORY
 





 First Name: MI:  Last Name: Suffix:
 Gender Birthdate:
 Height: Inches/Meters Weight: Lbs/Kilograms

Race/Ethnicity:
African American-American Black
Asian
Caucasian
Hispanic/Latin American
Native American
Pacific Islander
Other

Expecting/Nursing:
Client is Expecting    Due Date (dd/mm/yy):   # of Previous Pregnancies 
Client is Nursing

Actual Delivery Date

Risk Indicators:
Complications in Prior pregnancies?    Yes No  If yes, please explain  

Family History:  Pregnancy complications (Check all that apply): mother  sister   aunt

    Type of complications: Anemia Pre-eclampsia Eclampsia   Other

Major Concern:    Other Concerns:

Current Health Indicators:
Blood Pressure: systole   / diastole    Heart Rate  

Hematocrit   Protein in Urine   Electrolytes

Geographic Factors:   Country/Region/State/County

Date form completed (dd/mm/yy):

Send form to IPRS for Analysis

Not currently functional

Clinical  Tests
Not currently functional
Item/Category Description Value / Range
Blood Pressure

Serum Mg
Sugar in Blood OTC test kit
Sugar in Urine Dipstick test
 Protein/Albumin Urine Dipstick
Other  
 

Symptoms
Item/Category Description Intensity
Muscle Pain
Muscle spasms
Restless legs
Insomnia
Bladder Activity
Bowel activity
Migraine/headache
Nausea/Vomiting
Pulse rate
Flushing/Dizzy
Edema
Other

*Indicate above any changes from the usual with either (N)ormal, (L)ess than, or (M)ore than usual.

Not currently functional

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With  respect to your usual daily intake as described in the Intake Form, was this a usual day or was it more or less than usual?  Please indicate this in the tables below.


Food Intake:
   Usual
  Mineral-enriched foods
  Less than usual
Comment            

Fluid Intake:
   Usual
  Mineral-enriched liquids
  Less than usual
Comment               

Supplements/Medications Intake: 
   Usual
  Mineral-enriched supplements
  Less than usual
Comment               

Physical Activity: 
   Usual
  Much greater activity
  Less than usual
Comment               Not currently functional

If you want the full risk assessment complete this background form and submit it along with the Daily Intake Form EPNM-Sur to the address below.

Nutrient Analysis, 1162 Falling Stream, Sanford, NC 27332 or email it to:  myhealth@iprsinc.org

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 Version 1/20/2016, (c) IPRS