Personal Data

• Name : • Husband’s name.

• Age . • Husband’s age.
• Occupation. • Occupation.

• Residence. • Level of education.

• Blood grouping.
• Level of education.
• Consanguinity.
• Marital status.
• Duration of marriage.

• History of the present illness (complaint)

• DURATION
• ONSET
• Systemic enquiry
• Gravidity:
• Parity: after 24
• +…. abortion before 24 week’s:
Obstetrical history The past pregnancies
:   Duration   -
: Complications during pregnancy -
: Onset of labor -
        :  Duration of labour -
:Mode of delivery -
:Place of delivery  -
.Complications after delivery (retained placenta, PPH, DVT, UTI, psychosis, anaemia…etc)    -
• Outcome of the pregnancy:
1. - Newborn weight
2. -  Condition of the newborn (alive/dead, cried immediately, taken to N.I.C.U.
3. -  Breast-feeding / Bottle-feeding.
4. -  Age of the baby now / Milestones.
• In case of caesarean section you have to ask about:
-         Elective/emergency.
-         Cause of C/S.
-         Blood transfusion.
-         Complications
-         Stay in hospital.
• In case of stillbirth you have to ask about:
- Fresh/macerated.
-   Cause(S): HTN, DM, PROM, prematurity..etc
-        Weight of the baby.
-         Malformations.
-         Mode of delivery.
• In case of abortion you have to ask about:
-   Gestational age.
-   Spontaneous or induced.
-   Evacuated or not.
-   Blood transfusion.
-   Complications: bleeding, perforation,infection.
-   Possible cause(s).
• History of current pregnancy:
– LMP) The first day of the last menstrual period :
 (EDD) :
 calculate the gestational age (in weeks).
:Also ask about   
 .?When pregnancy test was done -
.?When the first ultrasound was done -
- When the first fetal movement (quickening).
• Then ask questions by trimester:
.In the first trimester ask about nausea, vomiting, bleeding and folic acid supplimentation - 
In the second trimester ask about the above questions + the use of iron and calcium, vaccination, - 
.fetal quickening, ultrasound, vaginal bleeding, antenatal visits
In the third trimester ask about: fetal growth and movement, any complication during this - 
.pregnancy (bleeding, hypertension, anaemia…etc)

      - Name.
        - Age.
        - G…P…+…
- Mode of delivery of previous deliveries.
        - Gestational age.
        - Cause of admission or complaint.
 
Example: this is Mrs. X, aged 28 years, G 4 P 2 + 1 all of them SNVD
at 30 week’s gestation and she came to the hospital with of
reduced fetal movements/labour pain
• Gynaecological history
• AGE OF Menarche.
• Kata. 5/28.‫عدد أيام ا لحيض‬
• The cycle:
 Pattern.
 Amount.
 Associated pain.
 Vaginal discharge (colour, amount, consistency, odour,
itching)
 Use of contraceptives.
 history of pap smear and mammography
 Sexual history
• Gynaecological surgery
 Past medical and surgical history 
 Hypertension.
 Diabetes.
 Asthma.
 Hospitalization.
 Blood transfusion
 Epilepsy
 HIV
 Venous thromboembolic disease (↑risk of Thromboembolism, pre-eclampsia, FGR)
 Connective tissue diseases (SLE) (↑risk of pre-eclampsia, FGR)
-       Type of operation including gynaecological operation (D&C , myomectomy… etc),
date and complication(s).
- Type of anesthesia used and complication(s).
 Family history  
– Hypertension,
– diabetes,
– asthma.
– Twin pregnancy.
– Congenital malformations/handicaps.
– Anaemia
– Cardiac disease.
 Drug history:
• Regular use of medication (chronic use).
• Allergy to any drug specially penicillin.
•  Pre-conceptual or early use of folic acid.
•  Current use of medication.

 Social history:
• Housing condition.
• Abnormal habit e,g smoking