Birthwell Shreveport Prenatal Visit Note

Confirm Client Name

Enter Client Name as submitted during intake process.

Confirm Client Email *

‼️Required to sync visit form to client. Ensure the registration email is on file and not a new or alternate email.

Section 1: Visit Details

Visit Date *

Prenatal Visit Type

Visit Category *

Visit Format *

Visit Duration *

Section 2: Services/Activities Provided

Gestational Age *

‼️Use the date of the visit when calculating. Entry follows this formula: 39 weeks and 4 days = 39.4. Use pregnancy calculator for assistance.

Visit Activities Provided *

Select all that apply

Other Visit Activities

Section 3: Client Assessment

Client Mood *

Client Emotional Notes

New Medical Pregnancy Concerns

Section 4: Visit Summary

General Visit Summary *

Client Reflections/Feedback

Follow-Up Plans *

Visit Status *

Use your organization's policies regarding when to select 'Follow up Needed'.

Enter reason(s) for 'Follow Up Needed'

Organization Tag

Provider Conducting Visit

Provider Signature- Visit *