SOCIAL SECURITY SYSTEM

OLONGAPO CITY
MEDICAL BENEFITS SECTION

NAME: ______________________________________ DATE: ____________________

SSS No.: _____________________________________

COMPLETE OBSTETRICAL HISTORY

(TO BE FILLED UP BY ATTENDING OB-GYNECOLOGIST)

A. OBSTETRICAL SCORE: _________________________________________

B. DETAILED OB HISTORY (COMPLETE DATA BELOW USING THIS FORMAT)

G1 - _______________________ ___________________________
DATE TYPE OF DELIVERY

G2 - _______________________ ___________________________
DATE TYPE OF DELIVERY

G3 - _______________________ ___________________________
DATE TYPE OF DELIVERY

G4 - _______________________ ___________________________
DATE TYPE OF DELIVERY

C. OTHER REMARKS (If any)

NOTE: This is serves as the Member’s Medical Certificate

_____________________
Printed Name & Signature
Attending OB – GYNE

PRC License No.: _______