Birth History

Mother’s age & health at the time of this pregnancy

Was there any illness, injuries, bleeding, or any complication during this pregnancy?
(If yes please describe:
___________________________________________________________________________
Duration of pregnancy: ________________
Emotional status during pregnancy: _________________
Duration of labour: ________________
Type of Delivery: Normal: _______ C-Section: _____ Vaginal: ______ Breech: _______
Place of Birth: _______________
1st Cry: Yes / No
Breathing Problem: Yes / No
Anoxia: Yes / No
Baby weight at the time of birth: _______
Jaundice: Yes / No
Any Fever: Yes / No (if yes) ____________
Birth Injury: Yes / No (if yes) ________
Congenital abnormalities: Yes / No (if yes) __________
Any other illness:
______________________________________________________________
Did your child had any sucking/ feeding difficulty Yes / No (if yes) ____________________
Developmental Milestones Achieving Age
Physical Millstones
Neck holding
Sitting
Crawling
Walking
Babbling
Speech (single word)
Two words speech
Talking (complete sentence)
Eating without help
Dressing without help
Taking bath without help
Bladder Bowl control

Menstrual History
What was your age at your 1st periods?

After your 1st period, have you ever experienced a time interval of 3 or more months when
you did not have a menstrual period?
[IF "YES": Was this one time only or more than once?]
What is the pattern of your menstruation cycle?
How many days you have periods?
What are your feelings during the periods?
Are you facing pain in any part of your body during menstruation?
Do you take any medication for menstrual pain?
Early Childhood History
Can you tell me the best event of your childhood?
What thing were made you cherish?
Who were very close to you in your childhood?
What was your relationship with your friends?
What were your hobbies?
What type of game you liked to play in your childhood?
What is your favourite dish?
Can you tell me a bad event of your childhood memory?
Did you ever fight with someone in your childhood?
Educational History
When did you start going to school?
How did you feel going to school for the first time?
How did you feel going to school for the first time?
How were you in studies?
What did your teachers think about you?
What did you think about your teachers?
How long did it take you to fit in at school?
How was your relationship with your classmates? Had you ever changed you? If yes then
why and how many times?
Have you ever failed a class?
Your favourite subjects?
What were your subjects in matric?
Did you choose your subjects by your own choice in matric?
Did you take admission in college?
Can you explain about your college life?
Why did you stop studying?
Have you ever participated in extracurricular activities?
If yes, then explain what type of activities?
Did you ever get bullied by your school or college mates?
Occupational History
When did you start your 1st job?
Which type of job it was?
Are you still doing job?
How much satisfied with your job?
If no then ask why?
How is your relationship with your boss?
How is your relationship with your colleagues?
Religious Orientation
Where do you place yourself on a scale of 10 regarding religious orientation?
How much regular are you in performing religious duties?
Marital/ Sexual History
At what age did you notice physical changes?
Did you know about menstruation before?
When did you start menstruating?
What did you feel about your physical changes?
What kind of changes in mood are seen after adulthood? Anger or irritability?
Has there been any kind of change in your feelings or emotions?
Were you touched in a wrong way as a child or young that you felt bad about?
(if yes) Did you tell anyone about this?
Has there been any change in your mood after this incident?
How many friends do you have?
Are there boys and girls among these friends?
Is there any close friend with whom you have an emotional connection?
What kind of relationship do you have with this friend?
Do you go out with him/ her?
Does this friend visit your house?
Did that friend ever stay the night?
Is it friendship or liking?
Have you ever expressed this liking?
Are these relationships important?
How long did the relationship last?
How did those relationships end?
How did you feel at the end of these relationships?
Are you married?
How is your relationship with your spouse?
What do you feel about your spouse
How is your married life?
How long have you been married?
How do you improve your marriage?
Do you have any child?
How many children do you have?
Drug Use
Have you ever taken painkillers without the prescription of doctor?
Have you ever used sedatives?
Have you ever tried any drug?
If yes
Then how much amount you were intake at once?
When were you started intake of drugs?
Why did you intake drugs for the first time? and how?
After intake, how did you feel?
Do you know the disadvantages of drugs use?
Does it affect your daily life activities and your relationships?
Does your family know about this?
What are the benefits and harms you get from drugs usage?
Do you want to quit drugs Use?
Forensic History
Have you ever faced any legal problems?
If yes, what kind of?