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Prenatal Checklist for Narra Hospital

This document contains a prenatal checklist for a patient of the Narra Municipal Hospital in Palawan, Philippines. It collects information such as the patient's name, age, address, emergency contact, last menstrual period, estimated due date, obstetric history, family medical history, past medical history including any conditions like hypertension or diabetes, history of previous pregnancies, number of living children, pregnancy complications, tetanus vaccination dates, ultrasound dates, and a section for notes and recommendations. The form is used to document a pregnant patient's medical history and lab results to monitor and manage their prenatal care.

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Nerie Joyce Mante
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288 views2 pages

Prenatal Checklist for Narra Hospital

This document contains a prenatal checklist for a patient of the Narra Municipal Hospital in Palawan, Philippines. It collects information such as the patient's name, age, address, emergency contact, last menstrual period, estimated due date, obstetric history, family medical history, past medical history including any conditions like hypertension or diabetes, history of previous pregnancies, number of living children, pregnancy complications, tetanus vaccination dates, ultrasound dates, and a section for notes and recommendations. The form is used to document a pregnant patient's medical history and lab results to monitor and manage their prenatal care.

Uploaded by

Nerie Joyce Mante
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Prenatal Checklist Form: A form capturing essential prenatal patient information including personal details, medical history, and pregnancy-related data.

Republic of the Philippines

Provincial Government of Palawan


NARRA MUNICIPAL HOSPITAL
Antipuluan, Narra, Palawan

PRENATAL CHECKLIST
PATIENT’S INFORMATION
NAME: ________________________________________________________ AGE: ______ DATE
LABORATORY RESULT
ADDRESS: _________________________________________________________________ DONE
CBC WITH
CONTACT PERSON IN CASE OF EMERGENCY:________________________________ PC
DATE OF FIRST VISIT (outside NMH): __________________ BT
DATE OF FIRST VISIT AT NMH: ________________________ Smoker: _______________
OGTT
LMP: _____________ ___________ stick/day
EDD: _____________ ___________ No. of Years VDRL
AOG: ____________ Alcoholic Drinker:
HBSAG
NUMBER OF PREGNANCY: ________________ _______________________
HIV
FAMILY HISTORY PAST MEDICAL HISTORY URINALYSIS
OTHERS:
( ) Unremarkable ( ) Unremarkable
( ) Hypertension ( ) Hypertension
( ) Diabetes Mellitus ( ) Diabetes Mellitus
( ) PTB ( ) PTB TETANUS VACCINATION
( ) Bronchial Asthma ( ) Bronchial Asthma 1ST DOSE
( ) Cancer ( ) Cancer
( ) Goiter ( ) Goiter 2ND DOSE

3RD DOSE
HISTORY OF PREVIOUS PREGNANCY
4TH DOSE
(YES: Y NO: N)
Date of Delivery 5TH DOSE
TYPE OF DELIVERY ULTRASOUND
NORMAL DELIVERY FIRST
CAESAREAN DELIVERY C/S SECOND

Reason of C/S THIRD


BIRTH OUTCOME NOTES:
ALIVE
MISCARRIAGE

STILLBIRTH

NUMBER OF CHILD/CHILDREN DELIVERED


SINGLE

MULTIPLE BIRTH: NO: _____

PREGNANCY-RELATED CONDITIONS/COMPLICATION
PREGNANCY INDUCED HPN

PREECLAMPSIA/ECLAMPSIA
BLEEDING DURING PREGNANCY
OR AFTER DELIVERY
OTHERS:

ADVISED:

HIGH RISK PREGNANCY? YES/NO

RECOMMENDATION
Republic of the Philippines
Provincial Government of Palawan
NARRA MUNICIPAL HOSPITAL
Antipuluan, Narra, Palawan

Republic of the Philippines Provincial Government of Palawan NARRA MUNICIPAL HOSPITAL Antipuluan, Narra, Palawan PRENAT
Republic of the Philippines Provincial Government of Palawan NARRA MUNICIPAL HOSPITAL Antipuluan, Narra, Palawan

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