Completion of Pregnancy AMS

Completion of Pregnancy Aeromedical Summary

Date: / Service: / USNUSNR (Active)USNR (Selres)USNR-FTSUSMCUSMCR / Rank: / O-1O-2O-3O-4O-5O-6E-1E-2E-3E-4E-5E-6E-7E-8E-9 / Age:
Last Name: / MI: / First Name
SSN
Command Name: / Command UIC:
Exam Facility: / Facility UIC:
POC Email: / POC Phone No.:

Outcome: Spontaneous miscarriage

(check one) Elective Abortion

Normal Vaginal Delivery

Caesarian Section

Date of pregnancy completion:

Weeks of gestation at completion:

Report of any complications encountered during pregnancy:

Information on the health of the child and mother following delivery:

Post Partum Course:

Other notes:

Attach post partum obstetrical note.

Flight Surgeon Signature

Printed Name:

Date