OBSTETRICS HISTORY SHEET

A. PATIENT’S PROFILE
1. Name: Mrs. Argueza
2. Marital Status: ____ Single__/___Married _____Separated ______ Widow
3. Age: 20 years old
4. Religion: __N/A_
5. Reason for this visit: Consultation
6. Occupation: __N/A_
7. Contact Number: 0916 -284- 3207
8. Name of Husband/Partner: Dominic Argueza
9. Occupation of Husband: ____N/A_____
10. Referring Physician: Dra. Camille Angara
B. MENSTRUAL HISTORY
11. Age at first period: _____N/A___
12. If your menstrual periods are regular, period starts every ___N/A__ days
13. If your menstrual periods are irregular periods starts every __N/A___
days
14. Duration of bleeding: ___N/A__
15. Does bleeding occur between periods? ___N/A__ Yes ___N/A__No
16. Does bleeding or spotting occur after intercourse? ___N/A___Yes __N/A__No
17. First day of Last menstrual period April 20, 2020 (Month) Day Year
18. Is pain associated with periods? __N/A_Yes __N/A_No __N/A__ Occasionally
19. If yes to 18 is it: ___N/A__before menses ___N/A__during menses ___N/A__both

C. HISTORY OF PREGNANCY (All pregnancies)

G-5 T-1 P-2 A-0 L-3 _____ Have never been pregnant
20. Obstetrical History including abortion & Ectopic (Tubal Pregnancy)
 Year Place Duration Hours Type of Complicati S Birth Present
of of of Delivery ons of e Weight Health
Deliv Pregnancy Labor Mother x
ery And/or
Infant

N N/A 37 weeks N/A NSD None N/ N/A N/A

/ A
A

N/A N/A 32 weeks N/A CS N/A N/ N/A N/A

A

N/A N/A 36 weeks N/A N/A N/A N/ N/A Alive and

A Decease
d

N/A N/A N/A N/A N/A N/A N/ N/A N/A

A

D. BIRTH CONTROL HISTORY

21. What birth control method/s do you currently use? __N/A_

E. SEXUAL HISTORY
22. Do you have a sexual partner? ___/__Yes ______No
23. Are there concerns about your sexual activity which you want to discuss with your
doctor? _________Yes ____/____No

F. PAST OBSTETRICAL SURGERY/GYNECOLOGICAL SURGERY /SURGICAL HISTORY

24. Check any that apply or _________No

SURGERIES YEAR

Cesarean Section N/A

G. OTHER PAST GYNECOLOGICAL HISTORY

25. Check any that apply
 __N/A_Venereal warts __N/A_ Endometriosis ____Others
__N/A_Herpes-genital __N/A_ Chlamydia
__N/A_ Syphilis__N/A_ Gonorrhea
__N/A_ Pelvic Inflammatory Disease__N/A_Vaginal Infections

H. PAST MEDICAL HISTORY: Check Any That Apply ___/___None

_____Arthritis _____Kidney Disease ______Asthma

_____ Diabetes _____ Gallstone ______ Emphysema ___Diet Controlled _____ Liver
disease (Including Hepatitis) ___ Pill Controlled _____ Epilepsy ______ HIV ___ Insulin
Controlled _____ Blood Transfusion ______ Eating Disorder ____ Hypertension
_____ Thyroid Disease
______Other:______________
____ Heart Disease

I. CURRENT MEDICATIONS (Include dose/amount/ per day)

Medication Dose Frequency

Oral Ferrous Sulfate 30 mg Once a day

Folic Acid 400 mcg Once a day

Tetanus Toxoid N/A N/A

J. DO YOU CURRENTLY
1. Smoke ____/___No ___Yes ____ Sticks/day _____Packs per day
2. Use alcohol ___/____No ___Yes ___wine(glass/day) __ Beer(bottles/day)
____Hard Liquor (Oz/day)
3. Use illicit drugs: ___/__No ____Yes If Yes: Type__________
Amount:_______
4. Exercises ___/__No ____Yes If Yes: Type:___________ How Often_________
K. ALLERGIES
1. Drugs: __/__No ____Yes If Yes: Name of Drug/s:______________
2. Foods: __/__No ____Yes If Yes: Name of Food/s: _____________

L. FAMILY HISTORY
__N/A___ Diabetes __N/A___Heart Disease __N/A___Cancer Pls.
Specify:___________
Others: N/A
If “yes” to any, please list affected relatives:
Name________N/A_________________ Relationship:____N/A______
Name: ______ N/A_________________ Relationship: ____N/A______
M. OTHER SYMPTOMS
____ weight loss ___hair growth ____ none of the above
____ weight gain ___hair loss
__/___other: vomiting four times per day, feeling dizzy and weak, nauseated especially in the
morning, smells sensitivity
____ Change In energy __/__Change in urinary function
____ Breast discharge
N. OTHER INFORMATION
Have you or the baby’s father or anyone in your family ever had the following.
Down Syndrome (Mongolism)? __/__No ___Yes
If yes:
Who:
Other Chromosomal abnormalities? __/_No ____ Yes
If Yes: Specify:____________________
Neural Tube Defect (spina bifida, anencephaly) __/__No ____Yes
If yes: Who:__________
Hemophilia or other coagulation abnormality? __/__No ____Yes
If yes: Who:_________
Muscular Dystrophy? __/__No ____Yes
If yes: Who:____________________
Cystic Fibrosis? __/__No ____
Yes If yes: Who:____________________

MRS. ARGUEZA June 28, 2020 10:00 am

Patient’s Name w/Signature Date Time

DR. CAMILLE ANGARA June 28, 2020 10:00 am

Physician’s Name w/Signature Date Time