HISTORY COLLECTION

I. BIOGRAPHIC DATA: -

Name of the mother:

Age:
Religion: Name of the Hospital:
Nationality: DOA:
Education: DOR:
Occupation: Ward:
Income: Bed no:
Marital Status: LMP:
Type of marriage: EDD:
Marital life: S.EDD:
Address: Obstetrical Score: G P L A D E
Gestational age:
Diagnosis:
Name of the father:
Age:
Education:
Occupation:
Income:
2. CHIEF COMPLAINTS:
3. MENSTRUAL HISTORY:
 Age at menarche:
 Menstrual cycle: Regular / Irregular
 No of days:
 Pain:
 Flow: Normal / Scanty / Heavy
 Dysmenorrhea:
 Any other:

4. OBSTETRICAL HISTORY:
1. Present Obstetrical History:
Sl. Trim- Hb Wt Immuni Iron and Treatment Complication Remar
no ester zation Folic ks

3
 2. Past Obstetrical History:
Sl. No ye MOTHER CHILD Re
N . of ar Gest Abor Ty Pla Se Ali Still wt im Co mar
o pre ation tion/ pe ce x ve birth mu mpl ks
gna al pre- of of niz icat
ncy age term deli atio ion
deli
/ ver n s
full- y ver
term y
1

Last child birth:

5. Family History:
Type of family: nuclear/ joint

History of twins:

History of HTN / DM / Thyroid / Epilepsy / TB / Asthma

Family tree:

Sl. Name Relation- Age Sex Education Occupation Health

no ship Status
1

6. PERSONAL HISTORY:
 Sleep & Rest:
 Bowel pattern:
 Bladder pattern:
 Habits: alcohol/ smoking/ tobacco chewing.
 Hygiene:

DIETARY HABITS:
 Vegetarian /non-vegetarian:
 Meals per day:
 PICA:
 Water intake per day:
Sl. Name of the food/ fruit Mostly Rare Occasional None
no

SEXUALITY HISTORY:
 Contraceptive history and practice: _________________________
 Sexually transmitted disease (if any): _______________________
 Type: ______________
 Treatment taken: _______________________

7. MEDICAL AND SURGICAL HISTORY:

a. Present Medical History:

b. Present Surgical History:

c. Past Medical history:

1.Type of medication used:

2.Length of the hospital stay:

3.Allergic medications:

d. Past surgical history:

1.History of any operation:

2.Length of the hospital stay:

3.Type of anesthesia:
 PHYSICAL EXAMINATION

GENERAL APPEARANCE:

 Body built: obese / average / thin

 Activity: dull / active
 Height:
 Weight:
 BMI:
 edema: Generalized / Localized__________

VITAL SIGNS:
 Temperature:
 Pulse:
 Respiration:
 Blood pressure:

SKIN:
 Color:
 Texture: dry/ moist

HEAD:
 Hair:
 Scalp: dandruff / healthy

EYES:
 Symmetry: yes / no
 Eyebrows: symmetry / asymmetry
 Eye lids: infection / healthy
  Eye lashes: infection / healthy
 Conjunctiva: pale / pink

EARS:

 Symmetrical: yes / no
 Hearing: yes / no
 Any discharge: yes / no____________

NOSE:
 Nasal septum: deviated / symmetry
 Nostrils: symmetry / asymmetry
 Discharges: yes / no___________

Mouth:
 Lip: moist / dry
 Teeth: cavities / tooth decay / clean
 Tongue: uncoated / coated
 Gums: healthy / bleeding
 Odor: unpleasant / pleasant.

Neck:
 Lymph nodes: enlarged / normal
 Thyroid gland: enlarged / normal
 Range of motion:

Chest:

 Heart sounds:
Extremities:
 Nails:
 Range of motion:
 Lower extremities:
 Upper extremities:
 OBSTETRICAL EXAMINATION

Breast Examination:

1. Breast: symmetry / asymmetry_______________

2. Tenderness: yes / no_____________
3. Lumps: yes/ no______________
4. Lymph node enlargement: yes/ no_________
5. Secondary areola: yes/ no
6. Nipples: erect/invert/cracked___________
7. Any discharges: yes / no_________
8. Montgomery tubercle: yes/ no

Abdominal Examination:

A. Inspection:
1. Size: __________________
2. Shape: _________________
3. Visible fetal movements: ________________
4. Linea nigra: _____________
5. Striae gravidarum: _____________________
6. Operational scars: ______________________

B. Palpation:
1. Girth of the abdomen: ____________
2. Fundal height: __________________
3. Fundal Palpation: _______________
4. Lateral palpation:
 Left __________________

Right _________________

5. Pawlick grip/pelvic grip II: _____________

6. Pelvic grip I: _______________

C. Auscultation:
1. Fetal heart rate per minute: ______________

D. Genitalia:
1. Vulva edema: yes/ no _________________
2. Any discharges: yes /no ___________________

5. Lab investigation:

Blood grouping: Rh:

HIV: HbsAg:

VDRL:

Sl. Name of the investigation Mother value Normal value Inference

no
1

5
6.Treatment (Rx) given:

7.Nursing needs:

8.Nursing care plan: