Format 1: Antenatal case record

Date: ________
Name: Age:
Address: Occupation:
Socioeconomic status: Religion: Caste:
Education:
Booked/ registered (number of antenatal visits in pregnancy):
Amenorrhoea
Chief complaints:

History of present pregnancy:

TRIMESTER 1 TRIMESTER 2 TRIMESTER 3

Menstrual history:
Past menstrual pattern:
LMP: EDD:

Name of student roll no. page no.

 Obstetric history:

Past medical/Surgical/drug history:

Family history:

Diet history:

Personal history:

General examination:
Built: Nourishment:
Height: Weight:
General condition:
Temperature: Pulse: Respiration: BP:

Pallor, Icterus, cyanosis, glossitis, angular stomatitis, JVP, Lymphadenopathy, clubbing,

goitre
Breasts:
Systemic examination:
CVS
RS
CNS

Name of student roll no. page no.

 Obstetric examination:
Inspection:
Palpation: Fundal height..........weeks
Symphysio-fundal height ........cms.
Abdominal girth: ......cms
Leopold’s 1stmanoeuvre
Leopold’s 2ndmanoeuvre
Leopold’s 3rdmanoeuvre
Leopold’s 4thmanoeuvre
Auscultation
Provisional Diagnosis:

Case summary:

FACILITATOR ASSESSMENT

Competency Assessment (B/M/E)

OG5.2 High risk pregnancy
OG8.2, OG35.5 Obstetric case history, Gestational age
estimation, obstetric formula

OG8.3 Obstetric examination

OG8.6 Nutritional history
OG35.3 Provisional diagnosis
OG35.8 Case summary

Remarks of the facilitator:

Signature of facilitator: Date:

Name of student roll no. page no.