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High Risk (Y/N):  

High Risk Type:  

FAMILY IDENTIFICATION
Mother ID Pregnant Woman's Age Husband/Father
P21010022881796
Name 20
Name
Sindhu NAVEEN KUMAR

District Mandal Village Caste

Mahabubnagar Mahabubnagar Urban Bandlageri (SC/ST/BC/OC/Minority)
BC-D

Mobile No. Husband/Father

7013662389
Mobile No.

EC Couple No. Aadhaar No. Bank Name Branch Name

EC271113 XXXXXXXX5846 STATE BANK OF INDIA GANESH NAGAR

Account No. IFSC Code

37183744527 SBIN0016375

PREGNANCY DETAILS
LMP Date EDD Date Blood Group RH Type
11-10-2022 15-07-2023 AB +ve

Last Delivery Name of the Facility Delivery Details

Conducted at
Govt

FACILITY DETAILS
Sub-centre Sub-centre ID ANM ANM Mobile No.
S.niranjanamma 9010244305

Asha ASHA Mobile No. AWW AWW Center No.

s sridevi 7989226965 Bandlageri II 1413084

AWW Mobile No. Ambulance Toll Free

Phone Number
102/108
BIRTH RECORD
Baby Gender Date of Birth Gender

Birth Weight
Regular Checkup Is Essential During Pregnancy By ANM

Regular Checkup Is Essential During Pregnancy by ANM

1st 2nd 3rd 4th 5th 6th 7th 8th 9th

Month Month Month Month Month Month Month Month Month

Month & Date

BP Have blood pressure (BP) checked at each visit.

HB %

Urine Have Urine examined at each visit.

Oedema Have Oedama examined at each visit.

Weight Have weight checkup at each visit. Gain at least 9-11 kg. during pregnancy.
Gain at least 1 kg every
month during the last 6 months of pregnancy.

T.D.Injection Take two T.D. Injections. T.D.1 when pregnancy is confirmed and T.D.2 after 1
month. (Fill in the date)
*Give one dose of T.D. if previously vaccinated within 3 years

Iron Tablets Take one tablet of iron folic acid a day for at least 6 months after first trimester.
Take at least 180
tablets. (Fill in quantity and date issued

Calcium Take two tablets of calcium per day for at least 6 months in 2nd & 3rd
Tablets trimesters

Albendazole Take single dose of tablet albendazole (400 mg) in 2nd trimester
Tablets
 ANC 1

Date of Visit Result

ANC Date

Period of gestation (weeks)

weight in Kgs

Pulse rate

Blood Pressure

Anaemia (Y/N) N

Oedema (Y/N)

Jaundice (Y/N) N

Height of uterus (in weeks)

Foetal Heart rate (Per minute)

P/V if done

Any Symptoms

Management/Treatment

Date of Next Visit

Signature of MO/Gynaecologist

INVESTIGATIONS

Result Result

CBP VDRL

CUE HIV

Blood group type AB +ve HBsAg

RBS Thyroid profile

USG Report If done for Early Pregnancy NA

 ANC 2

Date of Visit Result

ANC Date

Period of gestation (weeks)

weight in Kgs

Pulse rate

Blood Pressure

Anaemia (Y/N) N

Oedema (Y/N)

Jaundice (Y/N) N

Height of uterus (in weeks)

Lie/Presentation

Foetal movements

Foetal Heart rate (Per minute)

P/V if done

Any Sysmptoms

Management/Treatment

Date of Next Visit

Signature of MO/Gynaecologist

INVESTIGATIONS

Result

CBP

CUE

OGTT

RBS

USG Report1

TIFFA(If Done)
 ANC 3

Designated Facility for 3rd ANC:  

USG Scan(Y/N):  

Date of Visit Result

ANC Date

Period of gestation (weeks)

weight in Kgs

Pulse rate

Blood Pressure

Anaemia (Y/N) N

Oedema (Y/N)

Jaundice (Y/N) N

Height of uterus (in weeks)

Lie/Presentation

Foetal movements

Foetal Heart rate (Per minute)

P/V if done

Any Sysmptoms

Management/Treatment

Date of Next Visit

Signature of MO/Gynaecologist

Other Investigations-(Y/N) :
INVESTIGATIONS

Result
CBP

CUE

OGTT

Blood Urea

Serum Creatinine

Space for USG Reports 2/3

 ANC 4

Designated Facility for 4th ANC:  

USG Scan(Y/N):      

Revised EDD:      
3rd ANC Done at Designated Facility(Yes/No):  
Date of Visit Result

ANC Date

Period of gestation (weeks)

weight in Kgs

Pulse rate

Blood Pressure

Anaemia (Y/N) N

Oedema (Y/N)

Jaundice (Y/N) N

Height of uterus (in weeks)

Foetal Heart rate (Per minute)

P/V if done

Any Sysmptoms

Management/Treatment

Date of Next Visit

Signature of MO/Gynaecologist

Other Investigations-(Y/N) :

BIRTH PLANNING

Contact Details
Details EDD Date Facility
Name Mobile No.

Normal Pregnancy

High Risk Pregnancy

In case of emergency Free Transport (102/108)-

Delivery Details
Date of Delivery

Delivery Place

Delivery Outcome

Term/Preterm/Abortion

Complications, if any (Specify)

If at Institution, Period of Stay Post Delivery

Gender of Baby Weight of Baby

Cried immediately after birth

Injection Vitamin K

Name of the person who did delivery

Status
POST PARTUM CARE

3rd 7th 14th 21st 28th 42nd

1st Day
Day Day Day Day Day Day

Any complaints

Pallor

Pulse Rate

Blood Pressure

Temperature

Breasts (Soft/Engorged)

Nipples
(Cracked/Normal)

Uterus Tenderness
(Present/Absent)

Bleeding P/V
(Excessive/Normal)

Lochia (Healthy/Foul
Smelling)

Episiotomy/Tear
(Healthy/Infected)

Family Planning
Counselling (Y/N)

Any other Complications

and Referral
Requirements (Y/N)

If baby is less than 2 kg, contact ANM for support, for continued breastfeeding and Kangaroo
mother care

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