Room # ______

Date: ___________
Time:__________
Name:__________________________________
Age:_____
Civil Status:___________
Address:________________________________
OB Score:_____________
Labor pains
LMP:_________________
Onset:_________________
EDC:_________________
Duration:_______________
AOG:_________________
Interval:________________
Location:_______________
Bloody show:____________
History of Present Pregnancy
Prenatal Check-up:__________________________
TT doses:__________________________________
Vitamins:__________________________________
UTZ:______________________________________
Illness/Infection:____________________________
Meds taken:_______________________________
History of Previous Pregnancies
Complicati
Date
Place
Type
Assist
AOG
BW
ons
ed by
G
1
G
2
G
3
Past medical History:__________________________________
Allergies:____________________________________________
Family History
( ) HPN
( )DM
( )Asthma
( )Malignancies
( )Multifetal pregnancies
( ) Thyroid diseases
Personal Social
( ) Smoking ___ sticks/day for about ____ years
( ) Alcohol beverage drinking ( ) occasional ( ) frequent
Consumes _____ glasses, for about _____ years
Internal Exam: Dilatation:______ Effacement:______ Station________
BOW:___________ FH:_________ FHT:___________
Pertinent PE
findings:_______________________________________________________
Blood type:_________
HBsAg:_____________
Fathers name:___________________________ Age:____
Occupation:_______________
Smoking:_______________
Alcohol:_______________

OB:__________________________

Pedia:_________________________

Room # ______
Date: ___________
Time:__________
Name:__________________________________
Age:_____
Civil Status:__________
Address:________________________________
OB Score:_____________
Labor pains
LMP:_________________
Onset:_________________
EDC:_________________
Duration:_______________
AOG:_________________
Interval:________________
Location:_______________
Bloody show:____________
History of Present Pregnancy
Prenatal Check-up:__________________________
TT doses:__________________________________
Vitamins:__________________________________
UTZ:______________________________________
Illness/Infection:____________________________
Meds taken:_______________________________
History of Previous Pregnancies
Complicati
Date
Place
Type
Assist
AOG
BW
ons
ed by
G
1
G
2
G
3
Past medical History:__________________________________
Allergies:____________________________________________
Family History
( ) HPN
( )DM
( )Asthma
( )Malignancies
( )Multifetal pregnancies
( ) Thyroid diseases
Personal Social
( ) Smoking ___ sticks/day for about ____ years
( ) Alcohol beverage drinking ( ) occasional ( ) frequent
Consumes _____ glasses, for about _____ years
Internal Exam: Dilatation:______ Effacement:______ Station________
BOW:___________ FH:_________ FHT:___________
Pertinent PE
findings:_______________________________________________________
Blood type:_________
HBsAg:_____________

Fathers name:___________________________ Age:____

Occupation:_______________

Smoking:_______________
Alcohol:_______________
OB:__________________________ Pedia:_________________________