DEPARTMENT OF PHYSICAL THERAPY & REHABILITATION

GYNAE/OBS ASSESSMENT FORM

Name: S/O, D/O, W/O:

Age: Gender: Female

Marital status: Duration of marriage:

Occupation: Address:

Mode of Admission: Date of Admission:

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CHIEF COMPLAINTS:

OBSTETRIC HISTORY:

Gravida & Parity Multiple pregnancies

EA / GA
Details about anesthesia

Number of living children Health status of previous baby

History of previous deliveries History of breast feeding (post natal)

HISTORY OF GENITOURINARY SYSTEM:

 Burning sensation during micturition Retention of urine Polyuria or Oligour

 Dribbling of urine during coughing or other activities

 Abnormal vaginal discharge __________________

 Vaginal bleeding _______________________
  Vulval itching / discomfort / skin changes
 Abdominal / pelvic pain _____________
 Urinary symptoms – frequency / urgency / dysuria
 Bowel symptoms ___________________________
 Fever ___________________________
 Tiredness/fatigue __________________________
 Weight loss _______________________________
 Abdominal distension – uterine / ovarian malignancy

MENSTRUAL HISTORY
Age at menarche ________________________________________
Last menstrual period (LMP) _____________________________
Duration and regularity __________________________________
Flow ___________________________________________________
Menstrual pain __________________________________________
Menopausal symptoms ____________________________________
Hormonal contraceptives __________________________________
If postmenopausal – what age did they go through the menopause?
________________________________________________________

Irregular bleeding
Post-coital bleeding – e.g. cervical ectropion / STDs/ vaginitis

Intermenstrual bleeding:
_____________________________________________________________
Current contraception – COCP / POP / Depot / Implant / Implanted uterine device
OBSTETRICS HISTORY
Current pregnancy ______________________________
Gravidity ______________________________________
Parity _________________________________________

Each pregnancy:
 Current age of child
 Birth weight
 Complications – antenatal / perinatal / postnatal
Ask sensitively regarding miscarriages, terminations and ectopic pregnancies
_____________________________________________________________________

OTHER MEDICAL CONDITIONS

Surgical history – C-section / LETZ / prolapse repair / hysterectomy
Any recent hospital admissions? – When and why?

 Blood pressure

 Tuberculosis: Diabetes Mellitus Bronchial Asthma Cardiac Problems

 HIV Anemia (sickle cell anemia, thalassemia) Any history of seizers

DRUG HISTORY

________________________________________________________________

PERSONAL HISTORY
Any addiction – smoking or alcoholism

Sleeping habits

Lifestyle of the client

SURGICAL HISTORY :

Surgical procedure done during delivery

FAMILY HISTORY:
History of twin pregnancy in family____________________________

Congenital anomalies in any family member _____________________

PSYCHOLOGICAL HISTORY
________________________________________________________________

SOCIO-ECONOMIC HISTORY:
Occupation of the client & her husband ________________________________

OBJECTIVE EXAMINATION:

Vital signs: B.P Pulse R.R Temp

Inspection: Skin Scar

Palpation: Tenderness Edema

POSTURE:
Posture in lying, sitting, & standing
• Rounded shoulders Increased cervical lordosis (forward head posture)
• Increased lumbar lordosis Hyper extended knees

Gait: Wide Base of Support

ACTIVITIES OF DAILY LIVING:

 Is the patient independent and able to fully care for themselves?
__________________________________________________

 Can they manage self-hygiene/housework/food shopping?

___________________________________________________

 Is the illness interfering with these daily activities?

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SYSTEMIC EXAMINATION:
Cardiovascular _____________________________________________________________________

Respiratory ________________________________________________________________________

GIT_______________________________________________________________________________

Urinary ___________________________________________________________________________

CNS______________________________________________________________________________ 

Musculoskeletal ____________________________________________________________________

Dermatology _______________________________________________________________________

DIASTASIS RECTI ASSESSMENT:

MANAGEMENT:

SHORT TERM GOALS:

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3.

LONG TERM GOAL:

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3.

ELECTROTHERAPY:
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2.

3.

MANUAL THERAPY:

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2.

3.

EXERCISE THERAPY:

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2.

3.

HOME PLAN:

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