ANTENATAL HISTORY FORMAT I. Patient profile Full name Age (in years) Hospital No. I. P. No.

Marital status separated Education status ccupation Hus!and"s name Age (in years) Education status ccupation #ype o$ $amily Per capita income %ate o$ !oo&ing %ate o$ admission: !stetric score 'ravida : : : : : : : : : : : : Married / unmarried/ divorced/ : : :

%ate o$ last antenatal visit

Para A!ortion M#P (iving II. Reason for hospitalization / Chief o!plaints

nset %uration )everity *elieving $actors Aggravating $actors III. Menstr"al histor# $

Age at menarc+e %uration o$ cycles *egularity Flo, - +eavy/moderate scanty - clots - no. o$ days Any dysmenorr+oea *elie$ measures (ast menstrual period Period menstrual period I.. O%stetri histor#$ Present O%stetri histor# Is pregnancy con$irmed : /es / No

0+en1 ,+ere and +o, it ,as con$irmed 0+at test ,as done $or con$irmation 2uic&ening Immuni3ation Any more disorders li&e : .omiting1 +aemorr+oids1 +eart !urn1 !ac&ac+e1 !leeding1 varicose vein1 constipation1 leg cramps1 $ever1 leucorr+oea1 anore4ia1 insomnia1 ot+er complaints. Past O%stetri Histor#

)l No

%ate o$ delivery Place o$ !irt+ %uration o$ pregnancy

Met+od o$ delivery 5ourse o$ pregnancy

(a!or

.. Fa!il# Histor#$ 5ongenital diseases

Any +ereditary diseases Multiple pregnancy %ia!etes Heart disease Any mental retardation Hypertension or PIH (in mot+er/ sisters) #,in pregnancy I$ yes1 In ,+om 6 Mot+er / Fat+er 6 .I. Me&i al'S"r(i al Histor#$ 5+ild +ood disease 5+ronic disease li&e ast+ma1 dia!etes1 epilepsy Previous surgery In7uries especially o$ !ac& and pelvis Hepatitis1 )#%1 HI. History o$ anemia Any medication ta&en at present or past *eason $or use1 date stopped 8lood trans$usion1 allergic reaction .II. N"trition$ 'eneral nutrition 9 veg / non-veg Appetite 9 decreased/increased Any eating disorders :; +ours recall .III. Partner)s Health Histor#$ 'enetic a!normalities 5+ronic diseases In$ections <se o$ drugs suc+ as cocaine alco+ol

)mo&ing +a!its : to!acco1 cigarette )e4ually transmitted diseases 9 HI./ AI%) 8lood type I=. Ps# ho'so ial histor#$ Emotional c+anges e4perienced 0omen"s and $amily"s reactions to present pregnancy Family support system 9 Family mem!ers and $riends 5oping strategies (i$e style c+ange )ocial relations+ips ,it+ t+e neig+!ours Financial support ANTENATAL E*AMINATION 'eneral Appearance: Nouris+ment 8ody !uilt Heig+t 0eig+t .ital signs : : : : : #emp : Pulse : *espiration : 8.P.

Mental stat"s $ Hea& to foot e+a!ination $ )&in turgor:

Moisture : 0armt+ / #emp : Fa e$ Facial pu$$iness: (ips: Eyes: Peri-or!ital oedema: 5on7unctive : Pallor Mout+: #ongue: Chest$ #+ora4 : : 8reat+ sounds : : : Heart : A4illa 8reast : crust : )+ape )ymmetry o$ e4pansion posture : .esicular sounds 0+ee3ing / *+onc+i 5repitations Pleural ru! : +eart rate (ocation o$ ape4 !eat/ 5ardiac murmurs : any lymp+ node enlargement : any tenderness / pain$ul tense / dilated veins / ,armt+ / presence o$ Moisture 5yanosis1 dryness

Nipples A%&o!en

retracted / inverted / crac&ed

Inspection : present/not

)i3e1 s+ape1 contour1 $lan&s1 um!ilicus1 $oetal c+anges1 5ontractions

movements1 s&in Palpation:

- Fundal palpation: In$erence : (ie Presentation - (ateral Palpation: (e$t side 9 description *ig+t side 9 description In$erence : Position Pelvic palpation : In$erence : Presentation Engagement / not engaged Attitude - Pa,lic& 'rip: Fi4ed/ Mo!ile - First pelvic grip : %escription

Auscultation :

- FH* - r+yt+m - location

E+tri!ities : An&le oedema : 5apillary re$ill : 5yanosis :