MEDICINE AND OBSTETRICS HISTORY AND PHYSICAL EXAMINATION

©Bautista,CPIII & Aranas, DR

GENERAL DATA HISTORY OF PRESENT ILLNESS FOR PREGNANT PATIENTS

NAME / AGE / SEX LMP

ADDRESS PMP

BIRTHDAY AOG

BIRTHPLACE EDC

NATIONALITY SUMMARY OF OTHER CONSULTATIONS

RELIGION

MARITAL STATUS

OCCUPATION

ADMISSION DATE:

CONSULTATION NO:

INFORMANT

RELIABILITY

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

ONSET EXPOSURE Infectious Disease:

LOCATION CONSULTATION Place / Date:

RADIATION MEDICATION Drug / Dose:

DURATION Duration:

TIMING/Frequency Prescribed / Self-medicate

QUALITY Effect:

QUANTITY HOME REMEDIES Change of Position: Diet:

SEVERITY (1-10) Herbals: Massage / Rituals / Religious Beliefs:

PRECIPITANTS Effect:

ASSOCIATED SX EFFECTS TO ADL


PRENATAL HISTORY (Knew They Were Pregnant)

COGNIZANT Pregnancy: UTZ Date:

AOG: Result:

PT Date: UA Date:

Place (Home / Clinic / Health Care / OPD / Other): Result:

Result

PREGNANCY Planned / Unplanned AND Wanted / Unwanted OTHER TESTS

Abortion: With Attempt / Without Attempt

FIRST Date: MEDICATIONS DOSE INDICATION DURATION DATE GIVEN

PRENATAL CARE
Health Center / Private OB / OPD / Other 1

AOG: 2

SUBSEQUENT No. of times: 3

PRENATAL
CHECK-UP Monthly / Weekly / Every 2 weeks / Other 4

ASSOCIATED S/SX DATE MANAGEMENT VACCINATION DATE GIVEN QUICKENING

Nausea 1 HEALTH STATUS

Vomiting 2 NUTRITION

Urine Disturbance 3 INFECTION

Fatigue 4 DRUG INTAKE 1

Breast Tenderness 5 2

Breast Tingling ALCOHOL

Chloasma/Melasma --- SMOKING

Weight Gain kg / lbs: Prepregnant weight: RADIATION

OTHER S/SX DATE MANAGEMENT TOXIC CHEM

1 ACCIDENT

2 TRAUMA

3 TRAVEL

 OB-GYNE HISTORY

MENSTRUAL HX SEXUAL HISTORY

MENARCHE Date: SEXUAL Date of First Sexual Contact:

CONTACT
Duration: Age:

# pads/day: Contact Experienced:

Type of pads: Subsequent Contact:

Dysmenorrhea: + or – No of Sexual Partners:

Medication:

SUBSEQUENT Cycle: Regular / Irregular LAST SEXUAL Date:

MENSES CONTACT
Days: Partner’s Sexual History:

MENSES Duration: SEXUAL OUTLET

/ ACTIVITIES /
# pads/day: FUNCTIONS

Type of pads:

Dysmenorrhea: + or –

Medication:

MENOPAUSE Age:

S/Sx:

GYNE / NON-PREGNANT PATIENTS GYNECOLOGIC HISTORY

LMP STATUS

PMP GYNE ILLNESS

OB SCORE GYNE OPERATIONS

G/P T/P/A/L HORMONAL THERAPY

YEAR PLACE NSVD / CS STATUS SEX TPA COMPLI FAMILY PLANNING

G1 PAP SMEAR

G2 VACCINATION HPV:

G3

G4

G5

 PAST PERSONAL AND MEDICAL HISTORY

BIRTH NVD / CS

Place: Home / Hospital / Other

FEEDING Breastfed / Milk Formula / Mix

GROWTH

BEHAVIOR &
DEVELOPMENT
IMMUNIZATION 1 MEDICATIONS DOSE / DURATION INDICATION

2 1

3 2

4 3

ALLERGY Allergens: TESTS / PROCEDURES RESULTS

Manifestation: 1

Intervention: 2

Drug Reactions: 3

CHILDHOOD INTERVENTION SURGICAL TYPE DATE PLACE DX / REASON

DISEASES OPERATIONS
Chicken Pox ☐Yes ☐No 1 ☐Major ☐Minor

Measles ☐Yes ☐No 2 ☐Major ☐Minor

Mumps ☐Yes ☐No 3 ☐Major ☐Minor

Polio ☐Yes ☐No 4 ☐Major ☐Minor

OTHER DISEASES INTERVENTION INJURIES / DATE PLACE

ACCIDENTS
HTN ☐Yes ☐No 1

DM ☐Yes ☐No 2

PTB ☐Yes ☐No 3

Stroke ☐Yes ☐No ADMISSIONS / DATE / DURATION PLACE

CHECK-UPS
Others ☐Yes ☐No 1

1 2

2 3

 FAMILY HISTORY

AGE STATUS HEALTH CONDITION HTN ☐Yes ☐No Hematologic ☐Yes ☐No

FATHER ☐Living ☐Deceased DM ☐Yes ☐No Seizures ☐Yes ☐No

MOTHER ☐Living ☐Deceased Arthritis ☐Yes ☐No PUD ☐Yes ☐No

SIBLINGS (No. of Brothers _____ ) (No. of Sisters _____ ) PTB ☐Yes ☐No BPH ☐Yes ☐No

1 ☐Living ☐Deceased CVD ☐Yes ☐No Twinning ☐Yes ☐No

2 ☐Living ☐Deceased Asthma ☐Yes ☐No Chromosomal/Congenital ☐Yes ☐No

3 ☐Living ☐Deceased Allergies ☐Yes ☐No Heredofamilial Diseases ☐Yes ☐No

4 ☐Living ☐Deceased Cancer ☐Yes ☐No Others

5 ☐Living ☐Deceased Psychiatric ☐Yes ☐No

POSITION IN
FAMILY



SOCIAL AND ENVIRONMENTAL HISTORY

EDUCATIONAL SLEEP Habit: ALCOHOL

ATTAINMENT
SCHOOL ☐Private: _____________________________________________________________ Hour: TEA

☐Public: _____________________________________________________________ Sedative: COFFEE

STUDYING HABIT MILITARY SERVICE DIET Type: SMOKIMG Pack Years:

Water: Brand / Amount / Frequency:

Laxative:

RELIGIOUS BELIEFS OCCUPATIONAL HISTORY RECREATION Habits: VITAMINS/ 1

SUPPLEMENT
2

LIFESTYLE 1 3
(Active /
Sedentary) 2 4

LIVING Family / Friends / Relatives 3 ALTERNATIVE 1

ARRANGEMENT HCP
FINANCES 4 2

HUSBAND Age: ADL 1 TRAVEL 1

HISTORY
Work / Condition: 2 2

Habit: 3 3

HOME

No. of Storeys LOCATION

No. of Rooms WINDOW

TYPE
No. of VENTILATION
Occupants
No. of CR INTERPERSONAL
RELATIONSHIP

SOURCES OF Drinking: GARBAGE

WATER DISPOSAL
Domestic:

SANITATION Inside: TOILET TYPE

Outside

PETS 1

 REVIEW OF SYSTEMS

GENERAL ( ) fatigue, ( ) weight change, ( ) fever, ( ) chills, ( ) night sweats, ( ) dizziness GASTROINTESTINAL ( ) anorexia, ( ) nausea/retching, ( ) vomiting, ( ) dysphagia, ( ) hematemesis,

SKIN ( ) rash, ( ) itching, ( ) moles, ( ) sores, ( ) hives, ( ) pigmentation ( ) indigestion, ( ) melena, ( ) hematochezia, ( )heartburn, ( ) abdominal pain,

HEAD & NECK ( ) headache, ( ) trauma, ( ) pain, ( ) stiffness, ( ) swelling ( ) hernia, ( ) hemorrhoids, ( ) use of laxatives

EYES ( ) pain, ( ) diplopia, ( ) scotoma, ( ) visual dysfunction , ( ) dryness, ( ) redness, RENAL ( ) dysuria, ( ) hematuria, ( ) incontinence, ( ) nocturia, ( ) urinary frequency,

( ) tearing, ( ) use of corrective lenses ( ) dribbling, ( ) kidney stones

EARS ( ) difficulty hearing/ deafness, ( ) tinnitus, ( ) pain, ( ) discharges, GYNECOLOGICAL ( ) menarche (age), ( ) cycle, ( ) duration of menstruation, ( ) abdominal bleeding,

( ) vertigo/dizziness ( ) vaginal discharge, ( ) itchiness, ( ) dysmenorrhea/ pelvic pain, ( ) dyspareunia,

NOSE ( ) epistaxis, ( ) dryness, ( ) pain, ( ) discharges, ( ) obstruction, ( ) contraceptive use, ( ) history of venereal diseases, ( ) number of pregnancies,

( ) smell dysfunction, ( ) sneezing ( ) number and types of deliveries, ( ) abortions, ( ) birth control method,

( ) menopause (age)

MOUTH ( ) soreness, ( ) pain, ( ) ulcers, ( ) hoarseness, ( ) dryness, MALE GENITALIA ( ) pain, ( ) swelling, ( ) urethral discharge, ( ) hernias, ( ) testicular pain,

( ) gum and dental problems ( ) masses, ( ) history of venereal diseases, ( ) erectile dysfunction/ potency,

( ) sexual habits, ( ) ulcers

BREASTS ( ) discharges, ( ) lump/mass, ( )pain, ( ) bleeding, ( ) infection MUSCULOSKELETAL ( ) muscle pains, ( ) joint pains, ( ) cramps, ( ) weakness, ( ) stiffness,

( ) history of trauma, ( ) swelling, ( ) limitation of motion, ( ) backache

RESPIRATORY ( ) cough, ( ) dyspnea/shortness of breath, ( ) sputum, ( ) hemoptysis, ENDOCRINE and ( ) heat/cold intolerance ( ) weight/ change, ( ) polydipsia, ( ) polyphagia,
METABOLIC
( ) cyanosis, ( ) wheezing/ asthma, ( ) occupational exposure, ( ) polyuria, ( ) hair change

( ) tuberculosis/PTB exposure, ( ) past PPD, ( ) previous chest x-ray

CARDIAC ( ) chest pains/discomfort, ( )orthopnea, ( ) dyspnea, NERVOUS ( ) headaches, ( ) syncope, ( ) seizures, ( ) weakness, ( ) head trauma,

( ) paroxysmal nocturnal dyspnea, ( ) palpitations, ( ) undue fatigue, ( ) edema, ( ) stroke, ( ) sleep disorder, ( ) coordination problem, ( ) sensory disturbance,

( ) cyanosis, ( ) syncope, ( ) hypertension, ( ) past heart diseases, ( ) motor problem, ( ) tremors, ( ) memory

( ) exercise limits

VASCULAR ( ) intermittent claudication, ( ) leg cramps, ( ) ulcers, ( ) varicose veins PSYCHIATRIC ( ) headaches, ( ) syncope, ( ) seizures, ( ) weakness, ( ) head trauma,

HEMATOLOGICAL ( ) anemia, ( ) excessive bleeding, ( ) easy bruising, ( ) past transfusions ( ) stroke, ( ) sleep disorder, ( ) coordination problem, ( ) sensory disturbance,

( ) motor problem, ( ) tremors, ( ) memory

 PHYSICAL EXAMINATION

GENERAL SURVEY

BP RR PR TEMP HT WT IBW

SKIN

HEAD

EYES

EARS

NOSE

MOUTH & THROAT

NECK

BREAST

RESPIRATORY

CARDIAC

ABDOMEN Inspection:

Fundic height:

EFW (Fundic height _____ minus 11 if non-ballotable or 12 if ballotable x 0.155 = _____ kg)

FHT:

LM1:

LM2:

LM3:

LM4:

GENITALIA

SPECULUM

IE

BIMANUAL EXAM

RECTO-VAGINAL EXAM

EXTREMITIES

NEUROLOGIC