ANTENATAL ASESSMENT

IDENTIFICATION DATA

Name Ipno
Age Ward
Sex Unit
Education Diagnosis
Occupation LMP
Occupation of husband EDD
Address Date of admission
Doctors name
CHIEF COMPLAINTS
Onset : Sudden ______________ gradual ______________
Duration : hours_____________ days________________
severity : mild________ moderate_______severe_______
Reliving factors :
Aggravating factors

PRESENT OBSTETRICAL HISTORY

Gravida____ para____ living____ abortion_____
1sttrimester
morning sickness : yes _____ no____
nausea : yes______ no___ if yes specify mild_____moderate_____severe_____
Vomiting : yes _____ no____if yes specify no of times____ noofdays_______
2nd trimester
Heartburn : yes _____ no ____if yes specify mild _____ modrate__severe_____
Anorexia : yes _____ no___ if yes duration_____
Back ache : yes_____ no___ if yes mid____ moderate_____ severe ______
3rd trimester
Constipation : yes_____ no___ if yes specify duration _____
Varicose veins : yes____ no____
Lecurrohea : yes ____ no____ if yes specify _____duration ______ flow ____
other complaints
PAST OBSTERICAL HISTORY

baby
Date of Mode of Complications
S.No death stillbirth
delivery delivery
sex wt
antenatal labor puperium

PRESENT MEDICAL HISTORY

Hypertension ; _______ Diabetes _________ Thyroid disorders ________
Bleeding ;_________
PAST MEDICAL HISTORY
Child hood diseases _________
Measles : yes ___ no____ if yes specify ___________
chickenpox yes ____no_____ if yes specify _______
Chronic disease
asthma : yes ____no _______if yes specify ________
diabetes : yes _____no______ if yes specify ________
epilepsy : yes _____no _____ if yes specify________
Hepatits : yes ____no______ if yes specify_________
Anemia : yes _____no______ if yes specify _________ any blood transfusions _________
Accidents : yes _____ no______ if yes specify ________
Previous : yes ____ no_______ if yes specify______
hospitalization
PRESENT SURGICAL HISTORY
Ho/surgery : yes ______ no_______ if yes specify_____________
Type of anesthesia __________ local_______ or general_____________ spinal_____

PAST SURGICAL HISTORY

Ho / of surgery : yes _____ no_____ if yes specify _____________

Type of surgery : open _______ laproscopic __________
Type anesthesia : local________ general____________
Time and date :
Complications :
FAMILY HISTORY
PEDIDREE

sno Name of the family age sex education occupation Annual Health
member income status

PERSONAL HISTORY
Rest and sleep : hours of sleep_________ hours of rest ________
Habits time of : smoking ________ alcohol ________ pan chewing_
Dietary pattern : type of food ___________ veg____________ non veg__________
Staple food wheat ___________ jowar____________
No of times food taken per day
Bowel and bladder : frequency_______
Regular __________ irregular_________
Constipation __________ diarrhoea__________

SOCIO ECONOMIC HISTORY

Type of house : kachha__________ pakka _________ no of rooms ______
lighting ____________ ventiliation ___________
Drainage : closed _______ open _________
Latrine : yes ________ no ____________
Water supply : well ___________ bore well __________ tapwater ________
MARITAL HISTORY
Consanguineous marriage : yes_______ no _______
Type of family : nuclear _______ joint_______

MENSTRUAL HISTORY
Age of attaining menarche
Duration
interval of cycle
Flow : scanty moderate heavy clots
Any dysmennorhea

FAMILY PLANNING HISTORY

Type of method used : temporary ___________ permanent _____________
Duration : months __________ weeks___________ days _______________
side effects : yes ______ no _______________

PHYSICAL EXAMINATION

GENERAL APPEARANCE
Consciousness : conscious __________ unconscious ___________ drowsy ________
Body buil : emancipated__________thin __________ moderate __________ obese ___________
Activiy : mild _______ moderate ___________ heavy _____________
Health status : healthy__________ acutely ill ____________ chronically ill ____________
MEASUREMENTS
Weight
Height

HEAD
Hair
Scalp
FACE
Puffiness : present|_________ absent___________
Chloasma gravidaram : present _________absent_____________

EYES
Eyebrows :
Eye lashes :
Eye lids :
Conjuctiva :
Sclera :
Pupillary reaction :
Vision :
NOSE
Discharges :
Sense of smell :
EARS
Discharges :
Hearing :
MOUTH
Lips :dry______moist______ angular stomaitis_________
Gums :bleeding______ inflammation________
Teeth : discoloration_________ dental caries______
Tongue : pale_________ coated_________glossitis_________-

NECK
Enlargement of lymph nodes
thyroid gland
movement

CHEST
Shape :
Heart sounds : cardiac murmurs___________ palpitations____________ s1_______ s2___________
Breath sounds : Clear_________vesicular sounds ________ _
wheezing___________ crepitation_____________
pleural rub_______________
Breast : painful ____________________ tenderness_________ tense_________ warmth __________
dilated crust_______________presence crust_______
Nipple : cracked _______ _____________inverted ___________ retracted____________

ABDOMEN
Inspection
Size : appropriate _______ in appropriate_______--
Shape : round _______ oval_________
Skin changes : straie gravidaram________ linea nigra___________ previous lscs scar______
Umbilicus : dimpiled_________ protruded_________
Fetal :
movements
Flankful : present ______ absent____________
Cantour : relaxed ______ elastic__________

Palpation
Fundal palpation
Lateral palpation
 Left side
Right side

Pelvic Palpation
Grip1 :
Presentation : engaged ______ not engaged__________
Grip2
Ballotment : ballotable_______ no ballotble_________
Presentation___________ position________ lie_________

Auscultation
Fetal heart sounds
Location
Rhythm

EXTREMITIES
Upper extremities
Oedem present_______ absent________
cyanosis present_________absent_______
Lower extremities
Oedema present__________ absent________
Cyanosis present __________ absent_______

SPINE
Lordsis

GENTILIA
labia majora
labia minora
clitoris
vagina

VITAL SIGNS
Temperature
Pulse
Respiration
Blood pressure

ULTRASOUND FINDINGS :
INVESTIGATIONS

Name of investigation Normal values Patient values remarks

TREATMENT

Name Dose classification Mechanism Indication contraindication Side Nursing

of the of action effects responsibilities
drug