BIRTH PLAN OTHER SERVICES MOTHER’S RECORD

DATE CHIEF COMPLAINTS REMARKS

BARANGAY LAGO, GLAN, SARANGANI PROVINCE

Name: _______________________ Age: ______

Address: ________________________________
Birthdate: _____________ Blood Type: _______
Contact Number: _________________________
Name of father: _________________ Age: _____
Contact Number: __________________________

OBSTETRIC HISTORY:
G: ____ P: ____ A: ____ L: ____
STILLBIRTH (Y/N): _____ HEMORRHAGE (Y/N): ____
TETANUS TOXOID
TD1 TD2 TD3 TD4 TD5

WARNING SIGNS
POST PARTUM CARE

DATE OF DELIVERY: __________________________

TYPE OF DELIVERY: ___________________________
PLACE OF DELIVERY: _________________________
VIT. A: _________
IRON
1ST month 2ND month 3RD month

NAME OF CHILD: _____________________________ EMERGENCY CONTACT:

BIRTHDATE: _______________ SEX: _____________
WEIGHT AT BIRTH: _______
HEIGHT AT BIRTH: _______
NAME: _________________________________
RELATIONSHIP: __________________________
CONTACT NUMBER: ______________________
NAME: __________________________________
AGE: _______ BIRTHDATE: _________________
ADDRESS: _______________________________
LMP: _______________EDC: ________________
POSTPARTUM FAMILY PLANNING: ___________