ASSESSMENT TOOL FOR PHYSIOLOGIC CHANGES AND UNUSUAL SIGNS OF

PREGNANCY

NAME:_______________________________SEC:_____DATE:__________SCORE:___/45
NAME OF CLIENT:
___________________________________________________________________
AGE: ________________ EDUCATIONAL ATTAINMENT: ___________________________
OCCUPATION: ________________________________________________
RELIGION: _______________________
TYPE OF LIVING ARRANGEMENT: ____ Lives alone _____ Lives with family
____ Lives with partner/husband
Others; PLEASE SPECIFY:_____________________________________________
LAST MENSTRUAL PERIOD:
_______________________________________________________
AGE OF GESTATION/AOG:
______________________________________________________
Estimated Date of Confinement/EDC:
___________________________________________________
(Use NAEGELE’S RULE to identify EDC)
(1 point for each data given= 9 pts)
I. PHYSIOLOGIC CHANGES THAT ARE NORMAL DURING PREGNANCY

INSTRUCTION: Interview a pregnant client regarding 5 physiologic changes (normal

occurrence) that she experiences during her pregnancy. Document all response in the table
below. Include 3 health teachings that will help ease her discomfort.
(1 pt for each physiologic change, and 1 pt for each health teaching given = 20 pts)
PHYSIOLOGIC CHANGES HEALTH TEACHING
1. A.

B.

C.

PHYSIOLOGIC CHANGES HEALTH TEACHING

 2 A.

B.

C.

3. A.

B.

C.

4. A.

B.

C.

5. A.

B.

C.

If the clients has more than 5 normal physiologic changes, write them below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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II. UNUSUAL SIGNS AND SYMPTOMS/DANGER SIGNS DURING PREGNANCY

INSTRUCTION: Interview the client regarding 3 unusual signs and symptoms (conditions that
are not normal and could be danger signs) that she experiences during her pregnancy. Document
all response in the table below. Include 3 health teachings to help her achieve a safe and healthy
pregnancy.
(1 pt for danger sign, and 1 pt for each health teaching given = 16 pts)
UNUSUAL/DANGER SIGNS OF PREGNANCY HEALTH TEACHINGS
1. A.

B.

C.

2. A.

B.

C.
 3. A.

B.

C.

If the clients has more than 3 unusual/danger signs, write them below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________