OBSTETRICS AND GYNECOLOGY Cognizant, AOG: ________________________________________________

I. GENERAL DATA: Pregnancy test: _________________________________________________

Name: _________________________________________________________
Age: ____ Birthday: __________ Birthplace: ___________________________
Sex: ____ Nationality: _______________ Religion: ______________________
Marital Status: ( )Single ( ) Married ( ) Widow ( ) Separated
Address:________________________________________________________
Occupation: ____________________________________________________
Date of Admission/ Consultation: _____________ # Consultation: _________
Informant: __________________________ _________Reliability: ________%
II. CHIEF COMPLAINT:
______________________________________________________________
______________________________________________________________
PT at: Home/Clinic/Health Center/OPD/Other: ________________________
PT Result: ______________________________________________________
Pregnancy: Planned / Unplanned and Wanted / Unwanted
Pregnancy: With/Without Attempt of Abortion
1st Prenatal Care: ________________________________________________
Where: Health Center/Private OB/OPD/Other: ________________________
Prenatal Care AOG: ______________________________________________
Tests done: ____________________________________________________
______________________________________________________________
Subsequent Prenatal Check-up: ____________________________________
Monthly, Weekly, Every 2 weeks, Other: _____________________________
______________________________________________________________

III. HISTORY OF PRESENT ILLNESS: Associated signs and symptoms: (ask for the three trimesters)
Nausea: ______________ Date experienced: _________________________
For pregnant women: Management: __________________________________________________
 Contractions: ( ) with ( ) without Vomiting: ________________ Date experienced: ______________________
Management: __________________________________________________
Frequency _________________________________________________ Urinary Disturbances: ___________ Date experienced: _________________
Intensity ___________________________________________________ Management: __________________________________________________
Duration ___________________________________________________ Fatigue: ________________ Date experienced: _______________________
Breast tenderness & tingling sensation: ______________________________
 Vaginal bleeding ( ) with ( ) without Chloasma: ________________Date experienced: ______________________
Color _____________________________________________________ Melasma: ________________ Date Experienced: ______________________
# of pads __________________________________________________ Weight Gain: ______________ Prepregnant weight: ____________________
Duration __________________________________________________ Other Signs & Symptoms: _________________________________________
Ultrasound: ___________When: __________________# of times: _________
 Fetal movement ( ) with ( ) without Result: _________________________________________________________
Frequency _________________________________________________ Urinalysis: ______________________________________________________
Duration __________________________________________________ Result: _________________________________________________________
CBC: ____________ Result: ________________________________________
 Loss of fluid ( ) with ( ) without Other Test: _____________________________________________________
Color _____________________________________________________ Medication: ____________________________________________________
Amount ___________________________________________________ Indication: ______________________________________________________
Characteristic (trickling/gushing) ________________ time ___________ Dosage: ________________________________________________________
Duration: _______________________________________________________
 Other Date Given: _____________________________________________________
Vitamins/Food Supplements: _______________________________________
Discharges ( ) with ( ) without Color __________________ Duration: _______________________________________________________
Fever ( ) with ( ) without Characteristic: __________ Vaccination: ____________________________________________________
Dysuria ( ) with ( ) without Date Given: ________________________ By: Private/Health center/Hospital
Itching ( ) with ( ) without Location_______________ Quickening: _____________________________________________________
Shortness of breath ( ) with ( ) without EDC: __________________________________________________________
Health Status: ___________________________________________________
For non-pregnant: Nutrition: ______________________________________________________
Onset: Infections: ______________________________________________________
Duration: Intake of drugs: __________________________________________________
Frequency: Alcohol: ________________________________________________________
Location: Cigarette Smoke: ________________________________________________
Precipitating Factors: Radiation/X-ray: _________________________________________________
Quality: Toxic Chemicals: _________________________________________________
Radiation: Accident: _______________________________________________________
Trauma: _______________________________________________________
Severity: Travel: ________________________________________________________
Aggravating Factors:
Alleviating Factors: V. OB-GYNE HISTORY:
Previous Treatment for the Problem:
A. MENSTRUAL HISTORY
Associated Signs and Symptoms:
Menarche: _____________________________________________________
IV. PRENATAL HISTORY: (For those Who Knew They are Pregnant) Interval: Menstrual Cycle: ( ) Regular ( ) Irregular every: _____________
Duration: ______________________________________________________
Cognizant of Pregnancy: __________________________________________ Amount/# of pads/day: ___________________________________________
Type of Pads: ___________________________________________________
With or Without Dysmenorrhea: ____________________________________
Medication: ____________________________________________________
Other associated symptoms: _______________________________________
Subsequent Menses: _____________________________________________
Menopause/Age: ________________________________________________
Signs & Symptoms: _______________________________________________
FOR GYNE/NON-PREGNANT PATIENTS:
LMP: __________________________________________________________
B. OB SCORE
GP TPAL: Gravida _____________ Para ____________Term: _____________
Preterm: _______________ Abortion: ____________ Living: _____________
Year Place Delivery Status S T Complicat
(NSVD, (Live) e P ion
CS) x A
G1
G2
G3
G4
G5
C. SEXUAL HISTORY
1st Sexual Contact/Age:____________________________________________
Contact Experienced: _____________________________________________
Subsequent Contact: _____________________________________________
Contact Experienced: _____________________________________________
# Sexual partner: ________________________________________________
Last Sexual Contact: ______________________________________________
Partner’s Sexual History: __________________________________________
# Sexual Partner (partner): ________________________________________
Sexual outlet, activities, functions: __________________________________
D. GYNECOLOGIC HISTORY
Gynecologic illness: ______________________________________________
Status: ________________________________________________________
Gyne Operations: ________________________________________________
Status: _________________________________________________________
Hormonal Therapy: ______________________________________________
Status: _________________________________________________________
Family Planning: _________________________________Age started: ______
Status: _________________________________________________________
Pap smear:
Purpose: _______________________________________________________
When: ____________________________ By who: _____________________
Result: ________________________________________________________
Vaccination: (HPV Vaccine):________________________________________
VI. PAST PERSONAL & MEDICAL HISTORY:
Birth (NSVD/CIS): ________________________________________________
Place of Birth: Home/Hospital/Other: ________________________________
Feeding: Breastfed/Milk Formula/ Mix: _______________________________
Growth: ________________________________________________________
Behavior & Development: _________________________________________
Immunization: __________________________________________________
Allergy: ________________________________________________________
Allergy Manifestation: ____________________________________________
Allergy Intervention: _____________________________________________
Drug Reactions: _________________________________________________
Childhood Diseases (chicken pox, measles, mumps, polio): _______________
CD Intervention: _________________________________________________
Hypertension: _______________HPN Medication: _____________________
Diabetes: ___________________DM Medication: ______________________
PTB/Stroke/Other: _______________________________________________
PTB/Stroke/Other Medication: _____________________________________
Surgical Operations (Major/Minor): _________________________________
When & Where: _________________________________________________
Diagnosis/Reason: _______________________________________________
Injuries/accidents: _______________________________________________
When & Where: _________________________________________________
Hospital Admissions/Confinements/Check-ups: ________________________
When & Where: _________________________________________________
Duration: ______________ Diagnosis: _______________________________
Tests/Procedures: ________________________________________________
Lab tests: _______________________________________________________
Lab result: ______________________________________________________
Medications: ____________________________________________________
VII. FAMILY HISTORY:
Father/Age: ___________ Status: Alive:________, Deceased:_____________
Father’s Condition: _______________________________________________
Mother/Age: __________Status: Alive: ________, Deceased: _____________
Mother’s Condition: ______________________________________________
Siblings: #Brother: ___________________#Sister: ______________________
Siblings/Age: ____________________________________________________
Siblings/Health status: ____________________________________________
Position in the family: ____________________________________________
Heredofamilial diseases:
HPN: _____________ Diabetes: ___________ Arthritis: ________
PTB: _____________ CVD: _______________ Asthma: _________
Allergies: _________ Cancer: ____________ Psychiatric: _______
Hematologic: __________________ Seizures: ________________
Peptic ulcer: _________ BPH: ____________ Twinning: ________
Chromosomal/Congenital Abn: ____________________________
Others: _______________________________________________
VIII. SOCIAL AND ENVIRONMENTAL HISTORY:
Educational attainment: __________________________________________
School: ____________________________ ( ) Public ( ) Private ( )home
Where: ________________________________________________________
Religious activity/beliefs: __________________________________________
Occupational history: ____________________________________________
Husband/Age: __________________________________________________
Husband Work: _________________________________________________
Husband Condition: ______________________________________________
Husband habit: __________________________________________________
Activities of Daily Living: ___________________________________________
Sleeping hour: ___________________________________________________
Diet: __________________________________________________________
Drinking water: _________________________________________________
Recreational habit: ______________________________________________
Lifestyle: __________________(Activity: Active/Sedentary): _____________
Laxative/Sedative: _______________________________________________
Alcohol: _______________________________________________________
Tea: Coffee: ____________________________________________________
Vitamins/Food Supplements: ______________________________________
Cigarrette: _____________________________________________________
Brand/amount/frequency: ________________________________________
Pack years: = #of packs x # of years smoking: _________________________
History of travel: ________________________________________________
Alternative health care practices (massage, aromatherapy, acupuncture,
herbal, SPA): ___________________________________________________
Living arrangement (family/friends/relatives): _________________________
Physical and social aspect of home:
# Storey: ____________________ # rooms: __________________
# Occupants: _________________ # CR: _____________________
Window type: ________________ Ventilation: _______________
Location of residence: ___________________________________
Interpersonal relationship: ________________________________
Sanitation (inside and outside): ____________________________
Garbage disposal: _______________________________________
Type of toilets disposal: __________________________________
Pets: _________________________________________________
IX. REVIEW OF SYSTEMS:
1. GENERAL: ( ) fatigue, ( ) weight change, ( ) fever, ( ) chills, (
) night sweats, ( ) dizziness
2. SKIN: ( ) rash, ( ) itching, ( ) moles, ( ) sores, ( ) hives, ( )
pigmentation
3. HEAD and NECK: ( ) headache, ( ) trauma, ( ) pain, ( ) stiffness,
( ) swelling
a. EYES: ( ) pain, ( ) diplopia, ( ) scotoma, ( ) visual
dysfunction , ( ) dryness, ( ) redness, ( ) tearing, (
) use of corrective lenses
b. EARS: ( ) difficulty hearing/ deafness, ( ) tinnitus, ( )
pain, ( ) discharges, ( ) vertigo/dizziness
c. NOSE: ( ) epistaxis, ( ) dryness, ( ) pain, ( )
discharges, ( ) obstruction, ( ) smell
dysfunction, ( ) sneezing
d. MOUTH: ( ) soreness, ( ) pain, ( ) ulcers, ( )
hoarseness, ( ) dryness, ( )gum and dental
problems
4. BREASTS: ( ) discharges, ( ) lump/mass, ( )pain, ( )
bleeding, ( ) infection
5. RESPIRATORY: ( ) cough, ( ) dyspnea/shortness of breath, ( )
sputum, ( ) hemoptysis, ( ) cyanosis, ( ) wheezing/ asthma,
( ) occupational exposure, ( ) tuberculosis/PTB exposure, ( )
past PPD, ( ) previous chest x-ray
6. CARDIAC: ( ) chest pains/discomfort, ( )orthopnea, ( )
dyspnea, ( ) paroxysmal nocturnal dyspnea, ( )
palpitations, ( ) undue fatigue, ( ) edema, ( ) cyanosis, ( )
syncope, ( ) hypertension, ( ) past heart diseases, ( ) exercise
limits
7. VASCULAR: ( ) intermittent claudication, ( ) leg cramps, ( )
ulcers, ( ) varicose veins
8. GASTROINTESTINAL: ( ) anorexia, ( ) nausea/retching, ( )
vomiting, ( ) dysphagia, ( ) hematemesis, ( )indigestion, ( )
melena, ( ) hematochezia, ( )heartburn, ( ) abdominal pain,
( ) hernia, ( ) hemorrhoids, ( ) use of laxatives
9. RENAL AND INJURY: ( ) dysuria, ( ) hematuria, ( )
incontinence, ( ) nocturia, ( ) urinary frequency, ( ) dribbling, (
) kidney stones
10. GYNECOLOGICAL: ( ) menarche (age), ( ) cycle, ( ) duration
of menstruation, ( ) abdominal bleeding, ( ) vaginal discharge,
( ) itchiness, ( ) dysmenorrhea/ pelvic pain, ( ) dyspareunia,
( ) contraceptive use, ( ) history of venereal diseases, ( )
number of pregnancies, ( ) number and types of deliveries, ( )
abortions, ( ) birth control method, ( ) menopause (age)
11. MUSCULOSKELETAL: ( ) muscle pains, ( ) joint pains, ( )
cramps, ( ) weakness, ( ) stiffness, ( ) history of trauma, ( )
swelling, ( ) limitation of motion, ( ) backache
12. HEMATOLOGICAL: ( ) anemia, ( ) excessive bleeding, ( ) easy
bruising, ( ) past transfusions
13. ENDOCRINE AND METABOLIC: ( ) heat/cold intolerance ( )
weight/ change, ( ) polydipsia, ( ) polyphagia, ( ) polyuria, (
) hair change
14. NERVOUS SYSTEM: ( ) headaches, ( ) syncope, ( ) seizures,
( ) weakness, ( ) head trauma, ( ) stroke, ( ) sleep
disorder, ( ) coordination problem, ( ) sensory disturbance, (
) motor problem, ( ) tremors, ( ) memory
15. PSYCHIATRIC/ EMOTIONAL: ( ) anxiety, ( ) depression, ( )
loss of control/ violence, ( ) nervousness, ( ) memory change,
( ) suicide attempts, ( ) substance abuse
X. PHYSICAL EXAM
General Survey
Mood: _________________________________________________________
Distress/Unusual Position: _________________________________________
Cooperative / Non-cooperative: ____________________________________
Irritated / Agitated / Pleasant: ______________________________________
Coherent: ______________________________________________________
Oriented to time and space: _______________________________________
Personal Hygiene: _______________________________________________
Level of Consciousness: ___________________________________________
Height: _______________
Weight: ______________
BMI: _________________
Vital Signs
Temperature: _______
Respiration: ________
Pulse: _____________
Blood Pressure: _____
Head
Trauma: _______________________________________________________
Size: ______________________ Shape: _____________________________
Tenderness: ____________________________________________________
Condition of hair and scalp: ________________________________________
Symmetry: _____________________________________________________
Masses: _______________________________________________________
Eyes
Visual Acuity:
Far: (R) _________ (L) _________
Near: (R) _________ (L) _________
Visual Fields (H-test): _____________________________________________
Accommodation: ________________________________________________
Test of confrontation: ____________________________________________
Conjunctiva:
Color: _________________________________________________________
Discharge: _____________________________________________________
Sclerae
Color: _________________________________________________________
Discharge: _____________________________________________________
Cornea
Clarity: ________________________________________________________
Corneal Arcus: __________________________________________________
Lids: __________________________________________________________
Position of eyes in orbits: _________________________________________
Pupil
Size: (R) ____________ (L) ___________________
Shape: _____________ Symmetry: ____________
Accommodation: __________________________________
Light reflex test (PERLA): ____________________________
EOM: _________________________________________________________
Visual Field: ____________________________________________________
Direct Reaction: _____________Consensual Reaction: __________________
Fundoscopy
Red orange reflex: _______________________________________________
Disc: __________________________________________________________
Macula: ________________________________________________________
Blood vessels: ___________________________________________________
Ears
Symmetry: _____________________________________________________
Swelling: _______________________________________________________
Redness: _______________________________________________________
Discharge: ______________________________________________________
Tenderness: ____________________________________________________
Hearing Impairments: _____________________________________________
Presence of Hearing Aid: __________________________________________
Weber Test: ____________________________________________________
Rinne Test: (R) AC _______ (BC) _______
(L) AC _______ (BC) _______
Nose
Symmetry: _____________________________________________________
Frontal, Maxillary sinus tenderness: _________________________________
Obstruction: ____________________________________________________
Congestion: _____________________________________________________
Lesions: ________________________________________________________
Exudates: ______________________________________________________
Inflammation: ___________________________________________________
Throat
Lips: ___________________________________________________________
Teeth/dentures: _________________________________________________
Gums: _________________________________________________________
Tongue: ________________________________________________________
Pharynx: _______________________________________________________
Lesions: _____________________ Erythema: _________________________
Exudates: __________________ Tonsillar size: ________________________
Neck
Symmetry: _____________________________________________________
Limitation of ROM: _______________________________________________
Tenderness: ____________________________________________________
JVP: ___________________________________________________________
Lymph nodes: ___________________________________________________
Size: ___________________________________________________________
Mobility: _______________________________________________________
Tenderness: ____________________________________________________
Borders: _______________________________________________________
Consistency: ____________________________________________________
Thyroid Cartilage: _______________ Cricoid cartilage: __________________
Thyroid gland: ___________________________________________________
Chest and Lungs
Inspection
Comfort and Breathing Pattern: _____________________________________
Shape of the Chest: ______________________________________________
Chest Movement: ________________________________________________
Use of Accessory Muscles of Breathing: Deformities or Asymmetry
A/N Retraction of Interspaces on Inspiration Retraction of the
interspaces when breathing
Color of Patient (Lips and Nail Bed): _________________________________
Palpation
Tender Areas: ___________________________________________________
Respiratory Expansion (10th rib): ____________________________________
Tactile Fremitus:
Increased Decreased Absent
Percussion: _____________________________________________________
Auscultation: ___________________________________________________
Breath Sounds: __________________________________________________
Bronchophony Whispered Petoriloquy Egophony
_______________________________________________________________
Heart
Inspection
Precordial bulge or heave: _________________________________________
PMI: __________________________________________________________
Palpation
PMI: __________________________________________________________
Thrill: _________________________________________________________
Location: ______________________________________________________
Timing in Cardiac Cycle (S/D): ______________________________________
Mode of Extension / Transmission: __________________________________
Friction Rub: ____________________________________________________
Auscultation
S1 (M-loud, T-split): ______________________________________________
S2 (A,P-loud, P-split I): ____________________________________________
S3: ____________________________________________________________
Murmurs/ Accessory Heart Sounds:
Location:_______________ Timing:______________
Quality:________________ Pitch:_______________
Intensity:_______________ Radiation:___________
Breast
Symmetry: _____________________________________________________
Dimpling/Skin Retraction: _________________________________________
Swelling: _______________________________________________________
Discoloration (Skin changes): _______________________________________
Orange Peel Effect: _______________________________________________
Position and Characteristics of Nipple: _______________________________
Gynecomastia (Male): ____________________________________________
Mass:
Location:___________________________________
Size: _____________ Consistency:_______________
Tenderness:___________ Mobility:______________
Borders:____________________________________
Abdomen
Inspection
Irregular Contours:___________________________ Scars_______________
Discoloration: ___________________________________________________
Bulges: ________________________________________________________
Shape: _________________________________________________________
Striae:_________________________________________________________
Distance of umbilicus from xiphoid process: ___________________________
Abdominal Girth:_________________________________________________
Auscultation
Bowel Sounds: Frequency:__________________Character:_______________
Bruit:__________________________________________________________
Venous Hum:____________________________________________________
Friction Rub:____________________________________________________
Percussion
Liver Span:_______________________________Normal: 6-12 cm in (R) MCL
Splenic Dullness:_________________________________________________
Other Areas of Dullness: ___________________________________________
Special Tests
Rebound Tenderness:
Rovsing’s / Blumberg
Costovertebral Tenderness
Shifting Dullness
Psoas Sign
Murphy’s Sign
Extremities
Amputation_____________________________________________________
Visible joint swelling______________________________________________
Deformities Limitation of ROM Tenderness Redness ____________________
Warmth____________________ Edema______________________________
Capillary refill: _______R_______________________L __________________
Peripheral pulses: _______________________________________________
OB Assessment
Fundic Height: __________________________________________________
EFW: (Fundic height ___ minus 11 if non-ballotable or 12 if ballotable times
0.155 = _____ kg
FHT: _________________________________________________________
Leopold’s
LM1: ________________________________________
LM2: ________________________________________
LM3: ________________________________________
LM4: ________________________________________
Genitalia: ______________________________________________________
IE: ____________________________________________________________
Speculum: ______________________________________________________
Bimanual Exam: _________________________________________________
Recto-vaginal exam: _____________________________________________
Cranial Nerve Examination
CN I
Identify odorant
CN II
Visual acuity:_____________________ Visual Field: ____________________
Fundoscopy: ____________________________________________________
CN III, IV, VI
Size and Shape of Pupil: ___________________________________________
Light Reaction________________ Accommodation____________________
EOM:
Paresis_______________________ Nystagmus ________________________
Saccades_____________________ Oculomotor Ataxia __________________
Diplopia______________________ Other: ____________________________
CN V
Ophthalmic___________________ Maxillary__________________________
Mandibular___________________ Corneal Reflex______________________
Jaw Clench_____________________________________________________
CN VII
Eyebrow Elevation_____________ Forehead Wrinkling_________________
Eye Closure___________________ Smiling___________________________
Cheek Puffing___________________________________________________
CN VIII
Hear finger rub or whispered voice__________________________________
Rinne:_______________________ Weber: ___________________________
CN IX, X
Palate and Uvula: _______________________________________________
Gag Reflex_____________________________________________________
CN XI
Shoulder Shrug (against resistance) Head
Rotation (against resistance)
CN XII (Tongue)
Atrophy______________________ Fasciculation_______________________
Position with protrusion:__________________________________________
Strength:_______________________________________________________

NEUROLOGICAL EXAMINATION Mental Status

Examination
A. Awareness
Orientation
Name: Season Date Day Month Year
Name: Hospital Floor Town State Country Level of Consciousness:
B. Speech (Normal, dysphasia, dysarthria, dysphonia)
C. Language
Name: Pencil Watch
Repeat: “ No ifs ands or buts” D. General
Knowledge
Knowledge of current events, vocabulary (Historical events, 5 last
presidents, 5 largest cities)
E. Memory
Immediate, recent, remote F.
Registration (Retention and Recall)
Identify: Object 1 Object 2 Object 3 Attention and
Calculation
(100-7…): 93 86 79 72 65
Recall
Recall: Object 1 Object 2 Object 3 G. Reasoning
Judgment, Insight, Abstraction (interpretation of proverbs)
H. Object Recognition
Agnosia (Visual, tactile, auditory autotopagnosia, anosognosia)
Praxis (Ideomotor, Ideational)
Perception (Delusion, Hallucination, Illusion,
Astereognosis, Agraphestesia)
I. Follows Command
Take this paper. Fold it in half. Place it on
the table
Obey written Command. Write a
sentence
Copy a design.
Total: _____________________________________________