1.

________________________________ Age of the mother :

________________________________________________________ Name
of the husband :
________________________________________________________ Age
of the husband :
________________________________________________________
Education of the mother :
________________________________________________________
Educationof the husband :
_______________________________________________________
Occupation of the mother :
_______________________________________________________
Occupation of the husband :
_______________________________________________________ Family
income status :
________________________________________________________ Type
of the family :
_______________________________________________________
Socioecominicstatus :
_______________________________________________________ Date of
lastantenatal visit :
_______________________________________________________ Name
of the doctorto visit :
_______________________________________________________ Name
of the primaryhealth
centre:_______________________________________________________
Address :
_______________________________________________________
Obstetrical score GPALS :
_______________________________________________________ Age of
the marriage :
_______________________________________________________
2. 2. Use of contraceptives :
_______________________________________________________
Relationship withspouse :
__________________________________________________________
Diagnosis :
__________________________________________________________
Familyhistory Type of family :
__________________________________________________________
Congenital deformities : present/absent Hereditary disease : present/absent If
presentmention:
_____________________________________________________________
______
 _____________________________________________________________
_______________________
_____________________________________________________________
_______________________ Multi pregnancies :
_____________________________________________________________
____ Menstrual history Age of at menarche :
___________________________________________________________
Durationof menstrual cycle :
___________________________________________________________
Menstrual cycle regularity :
___________________________________________________________
Dysmenorrheal /leucorrhea/menorrhagia :
_______________________________________________ Duration :
_____________________________________________________________
Last menstrual cycle : date ……………………
month………………………….. Presentobstetrical history Periodof
gestational weeks :
______________________________________________________ Date of
confirmation of pregnancy :
______________________________________________________ Last
menstrual period :
_____________________________________________________
Expecteddate of delivery :
_____________________________________________________
3. 3. Quickening :
_____________________________________________________ Gravid :
_____________________________________________________ Para :
_____________________________________________________
Investigation: Sl no Investigation result Minor disorders :
_____________________________________________________________
______
_____________________________________________________________
________________________ If any, specify :
_____________________________________________________________
_______
_____________________________________________________________
________________________ Antenatal examination parameters 1st month
2nd month 3rd month 4th month 5th month 6th month 7th month 8th month
9th month Weight(kg) Weight increase (kg) Height(cm) temperature pulse
respiration Blood pressure
4. 4. Urine test Sugar :
_____________________________________________________________
____________ Albumin :
_____________________________________________________________
____________ Inspection: General appearance :
_____________________________________________________________
___ Stature (normal/short) : __