Name: Present Address:

Age: Admission times:

Birthday: G ___ P ___ ( - - - )
Birth place OB consultant:
Marital status:

CHIEF COMPLAINT:

HPI:

LMP: PMP: EDC: by LMP AOG: by LMP

by ULTZ by ULTZ

PRENATAL HISTORY
Cognizant at ___ weeks AOG due to ( ) amenorrhea, ( ) weight gain, ( ) cravings
With/without pregnancy test done ____x done at ____.
Un/planned Un/wanted With/Without attempts of abortion

FIRST TRIMESTER:
First/No PNCU done at _____ AOG with ( ) PMD, ( ) RHU, ( ) OPD
Total of PNCU: _____
Symptoms: ( ) Nausea, ( ) Vomiting, ( ) Dizziness, ( ) Fatigue, ( ) Sleepiness, ( ) constipation, ( ) diarrhea, ( ) cravings, ( ) weight gain, ( ) mood
swings, ( ) smell insensitivity, ( ) increased appetite, ( ) headache, ( ) breast engorgement

Illnesses: ( ) fever, ( ) cough, ( ) colds, ( ) rashes, ( ) diarrhea, ( ) UTI, ( ) bleeding, ( ) vaginal discharge, ( ) abdominal pains

Ultrasounds:

Laboratory tests: ( ) HbsAg, ( ) Syphilis, ( ) HIV, ( ) OGTT, ( ) FBS, ( ) CBC, ( ) UA, ( ) Lipid profile

Medications:

Travel history: __________ Exposure to COVID: ____________

SECOND TRIMESTER:
Total of PNCU done at _____ AOG with ( ) PMD, ( ) RHU, ( ) OPD
Symptoms: ( ) Nausea, ( ) Vomiting, ( ) Dizziness, ( ) Fatigue, ( ) Sleepiness, ( ) constipation, ( ) diarrhea, ( ) cravings, ( ) weight gain, ( ) mood
swings, ( ) smell insensitivity, ( ) increased appetite, ( ) headache, ( ) breast engorgement

Illnesses: ( ) fever, ( ) cough, ( ) colds, ( ) rashes, ( ) diarrhea, ( ) UTI, ( ) bleeding, ( ) vaginal discharge, ( ) abdominal pains

Ultrasounds:

Laboratory tests: ( ) HbsAg, ( ) Syphilis, ( ) HIV, ( ) OGTT, ( ) FBS, ( ) CBC, ( ) UA, ( ) Lipid profile

Medications:

Travel history: Exposure to COVID:

THIRD TRIMESTER:
Total of PNCU done at _____ AOG with ( ) PMD, ( ) RHU, ( ) OPD
Symptoms: ( ) Nausea, ( ) Vomiting, ( ) Dizziness, ( ) Fatigue, ( ) Sleepiness, ( ) constipation, ( ) diarrhea, ( ) cravings, ( ) weight gain, ( ) mood
swings, ( ) smell insensitivity, ( ) increased appetite, ( ) headache, ( ) breast engorgement

Illnesses: ( ) fever, ( ) cough, ( ) colds, ( ) rashes, ( ) diarrhea, ( ) UTI, ( ) bleeding, ( ) vaginal discharge, ( ) abdominal pains

Ultrasounds:

Laboratory tests: ( ) HbsAg, ( ) Syphilis, ( ) HIV, ( ) OGTT, ( ) FBS, ( ) CBC, ( ) UA, ( ) Lipid profile

Medications:
Travel history: Exposure to COVID:
Quickening felt at: _____ AOG , ( ) good fetal movements, ____ number of fetal kicks in 2 hours
Total of PNCU: _______ Tetanus toxoid:___________ Covid Primary booster: _______ COVID booster: _________
Other vaccines: ( ) HepB , ( ) Influenza

OBGYNE HISTORY
MENSTRUATION HISTORY
Menarche: ___ years old, ____ duration, _____ moderate/fully soaked pads per day, with/without dysmenorrhea
Subsequent menses: ______ interval, ______ duration, ______ moderately/fully soaked pads per day, with/without dysmenorrhea, headache,
vomiting, nausea,

OB SCORE: G:______, P: ______ ( - - - )

DATE PLACE MANNER OUTCOME SEX WEIGHT COMPLICATIONS
G1 L,F,T
G2 L,F,T
G3 L,F,T
G4 L,F,T
G5 L,F,T
G6 L,F,T

GYNE HISTORY
( ) Gynecologic illnesses in the past (infection, PCOS, myoma, polyps, malignancies, abnormal bleeding, gyne operations)
( ) HPV vaccination ( ) Family planning (OCP, injectibles, implants) ( ) PAP smear

SEXUAL HISTORY
Coitarche:_____ years old, with/without bleeding, with/without dyspareunia
Subsequent sexual contacts:
Number of partners: _______ ; Number of past partners:_____, Known STDs of partners: _____ ; STD tests done: ________
Last sexual contact:
Contraceptions used:

PAST MEDICAL HISTORY:

( ) HTN, ( ) DM, ( ) CVD, ( ) Thyroid disease, ( ) Allergies to food, ( ) allergies to drugs
( ) asthma, ( ) past surgeries, ( ) accidents ( ) CKD, ( ) cancer

FAMILY MEDICAL HISTORY

( ) HTN, ( ) DM, ( ) CVD, ( ) Thyroid disease, ( ) Allergies to food, ( ) allergies to drugs
( ) asthma, ( ) past surgeries, ( ) accidents ( ) CKD, ( ) cancer ( ) twinning

SOCIAL AND ENVIRONMENTAL HISTORY

( ) Smoker, ( ) Alcohol beverage, ( ) Travel history, ( ) Illicit drug use

PHYSICAL EXAMINATION
GS: Awake, conscious, coherent, ambulatory, ____ morph, not in cardiopulmonary distress
VS: BP:________ HR:______ RR:______ T:_______ SPO2:______ Pre-pregnant wt:_______ Current wt: _______ Ht:________ BMI: ____

SKIN: No cyanosis, no pallor, no jaundice, no rashes, warm to touch with good skin turgor
HEENT: Anicteric sclera, pink/pale palpebral conjunctiva, no eye or nasal discharge, no tragal tenderness, no TPWC, no CLAD, no neck mass
C/L: A/symmetric chest wall expansion, no lagging, no retractions, hyper/resonant, equal tactile and vocal fremitus, clear breath sounds, no
crackles, no wheezes
HEART: A/dynamic precordium, PMI at 5th ICS LMCL, no heaves/thrills, normal rate, regular rhyhtm, no murmurs
ABDMONEN: Gravid, with striae gravidarum, linear nigra, ____ active bowel sounds, tympanitic, ____ tender on palpation, soft/rigid, ( ) guarding,
( ) Rovsing’s, ( ) obturator, ( ) psoas, ( ) heel jarring, ( ) dunphy’s, ( ) splenomegaly

LM1: podalic/cephalic pole occupies the fundus LM2: Fetal back occupies the _____, fetal small parts occupies the ____ of the mother
LM3: Cephalic/breech/transverse, non/ballotable LM4:

FH: _______ cm EFW: _______ kg

FHT: ______ Location: _______

GUT: ( ) CVA tenderness

Speculum exam: Palpable vaginal rugae, pink cervix, open/closed cervix, ( ) vaginal bleeding, ( ) vaginal discharge:
IE: ______ cm, ______ % effaced, _______ presenting part, ________ station, ______ BOW (clear/thinly/thickly stained), no/blood on finger
Contractions: Interval: _____ minutes, Duration: _____ minutes, Intensity: _______