Name of Patient Pt. Blood Group Pt.

Age
Husband’s Name Husband Blood Group: Husband’s Age
Married Since: Gravida Para Miscarriage Abortion

(C1/(C2) I.NMP (C3) Sure (C4) Unsure (C5) Specify (C6) NMC (C7) Regular

(C8) EDD (C9) EDD (USS)

(01) Any Vaginal Bleeding Since last period (D2) Specify

(F1) Oral (E2) Specify (E3) Other Contraceptive

Contraceptives (E4)/(E5) Specify
Past Medical History (F1) Hypertension (F2) Diabetes (F3) Recurrent UTI (F4) Endocrine dysfunction

(F5) Anemia (F6) Haemoglobinopathy (F7) Hepatitis (F8) Cardiac Problem

Past Sugical History (F5) Abdominopelvic Surg. (F10) Blood trasfusion (F11) Anaesthetic Problem (F12) Any
other operation
(F13) Infertility

Family History: Wife (G1) Diabetes (G2) Hypertension (G3) Multiple pregnancy (G4) Congenital Anomalies (G5)
Haemoglabinopthies

Family History: Husband (G6) Diabetes (G2) Hypertension (G8) Multiple pregnancy (G9) Congenital anomalies (G10)
Haemoglobinopathies (H1) Family Members (H2) Hormol. M. Relation (H3) Healthy Attitude (H4) Drug
Abuse (H5) Smoking

(H6) Family Type (J) (S) (H7) Cousing Marriage (H8) Current Drug use of Women

(J1) Cx. Cytology Date

PREVIOUS PREGNANCIES

Dura Mod Matu Post- Puer Wei Age Any other

tion e rity Natal periu ght & significant
of in carn0 m of Sex Facrors (eg.
of
labou week ..." (like Baby Eclampsia.
Deliv (K10/
r >12 s (III & den, PIH Cx Suture
Spont er), (K9) K11)
hrs (47 IV ssion, Fatal
.
>12 . wks) Stage DVT Anomaly Rh
Induc
hrs ) sepsi Incompati.)
Year Place ed (K6)
(K4) (K5) s) (K12)
of of Labo (K7)
Birth Birth ur (K8)
(K1) (K2) (K3)