Questions *Theoretical Findings *Actual Findings

Woman’s or mother’s reason

in seeking for health care

Current Health/Illness Status

Symptom analysis of the chief

complaint?

Other current or recurrent

illnesses or problem?

Any other health concern?

Current Medications Used?

Past History

Previous illnesses, injuries, or

surgeries?

Allergies

Immunization

Review of System

General : Overall Health

Status
a. Physical appearance
b. Hygiene
c. Behavior

Vital Signs
a. Temperature
b. Pulse
c. Respirations
d. Blood Pressure
e. Height and Weight

Skin, Hair and Nail

a. Inspect the skin
b. Inspect and Palpate
hair (distribution and
characteristic)
c. Inspect and Palpate
nail (texture, shape,
color, condition)

Head and Neck

a. Inspect and Palpate
the head (symmetry,
normal contour,
tenderness)
b. Inspect and Palpate
the face (extra
pigmentation)
c. Inspect and Palpate
the neck (thyroid)

Mouth, Throat, Nose and

Sinuses
a. Inspect the mouth
(pay particular
attention to the teeth
and the gingival
tissues, which may
normally appear
swollen and slightly
reddened), teeth
b. inspect the throat
c. Inspect nose and
sinuses (discharge,
tenderness,
turbinates, color and
swelling)

Eyes
a. Inspect external eye
b. Perform visual acuity
test
c. Perform extraocular
muscle test

Ears
a. Inspect external ears
b. Perform internal
(otoscopic)
examination
c. Assess hearing acuity

Thorax and Lungs

a. Inspect shape of
thorax and respiratory
effort
b. Percuss the lungs
c. Ascultate for breath
sounds and
adventitious sounds

Breasts
a. Inspect and Palpate
breasts and nipple for
symmetry and colour

Peripheral Vascular
a. inspect face and
extremities (note colour
and edema)
b. Percuss deep tendon
reflexes

Cardiovascular/Heart
a. Inspect and Palpate
precordium
b. Ascultate heart
sounds

Gastrointestinal/Abdomen
a. Inspect the abdomen
(note striae, scars, and
the shape, and size of
abdomen)
b. Palpate the abdomen
(note organ and any
mases)
c. Palpate for fetal
movement after 24 wk

d. Palpate uterine
contraction (note
intensity, duration,
 and frequency of
contractions)
e. Time the length of the
contractions from the
beginning to the end
(note the frequency of
the contractions,
timming from the
beginning of one
contraction until the
beginning of the next
f. Measure fundal height
g. Fetal position (using
leopolds maneuvers,
Palpate the fundus,
lateral aspects of the
abdomen, and the
lovwer pelvic area
h. Fetal Heart
(Determine the
location, rate and
rhytm of the fetal
heart)

Female Genitalia
a. Inspect external
genitalia (note hair,
distribution, color of
skin, varicosities, and
scars)
b. Palpate Bartholins and
skenes gland
c. Inspect vaginal
opening for cystocele
or rectocele
d. Inspect internal
genitalia (visualize the
cervix, noting position
and color
e. Perfom pelvic
examination
f. Palpate the left and
right adnexa

Anus
a. Inspect anus and
rectum (note color,
varicosities, lesions,
tears or discharge

Musculoskeletal
a. Determine pelvic
 adequacy for a vaginal
delivery by estimating
the angel of subpubic
arch
b. Determine the height
and inclination of the
symphysis pubis
c. Palpate the lateral
walls of the pelvis
d. palpate ischial spine
(sweep fingers
posterior from one
spine over to the
other spine)
e. Examine the sacrum
and coccyx (sweep
finger down the
sacrum, gently press
back on the coccyx to
determine mobiity)

Nutritional History

Determine the quantity and

the type of food or formula
ingested daily: use 24-hour
recall, food diary for 3 day (2
weekdays and 1 weekend
day), or food frequency
record

Any problem with feeding

Any vitamin supplements

used

On special diet

Any cultural or religious

preferences on diet

Assess dieting behavior:

 Body image
 Type of diets
 Frequency of weighing
 Use of self-induced
vomiting, laxatives, and
diuretics

Sleep History

Sleeping Duration
Quality of sleep

Nap history

Sleep aids

Psychososial History

Home : composition of family

members,
accupations/education of
members, culture and
religion, communication
patterns,family roles and
relationships, financial status

Woman typical daily activities

Type of support system at

home, primary support
system

Substance use: amount,

frequency and circumtances
of use for tobacco, alcohol,
licit and illicit drugs, steroid,
and substances such as
inhalants?

Violence: domestic violence,

self-abusive behaviors,
suicide ideation and
attempts, violence
perpetrated on other by
child/adolescent being
interviewed?