Now, try some big leap.

RLE Activity 2: Comprehensive Obstetric Health History taking

Instructions:
1. All questions apply to this activity pertains to the concepts and theories discussed. Your responses
should be detailed and direct to the point. When asked to provide several answers, list them in order
of priority or significance.
2. Please submit on or before _______, 2020 thru MS Teams and or to the designated place in your
barangay,
and to be collected by PNC personnel.

Keep going.
Conduct an interview to a pregnant woman via Messenger of Zoom. Fill- up data completely while
interviewing the client. Use the form below.

OB/GYNE PATIENT HEALTH HISTORY FORM

A. NAME: _AAD Age: 34 DOB: March 2, 1986

Marital Status: Single Long-term Relationship Separated Others:
Reason for visit: -----------
Religion: Roman Catholic
Occupation: Housewife
Address: Southville 1, Niugan, City of Cabuyao, Laguna
Preferred phone number: ----------

B. PRESENT HEALTH HISTORY

She noticed that she feels weak, fatigue and feels nauseated and vomiting every morning.
She feels hungry and sleepy all the time.
C. MENSTRUAL HISTORY
First day of Last Menstrual Period: 02 /08 / 2020 Age of first period: 10 years old.
Age of Gestation: Based on LMP: 8 months, 1 week, 3 days Based on Ultrasound: 8 months
Expected Date of Delivery: Based on LMP: November 15, 2020 Based on Ultrasound: Nov. 5,2020

Your periods occur every 28 days and last for 4 days

Any problems with your periods? No □ Yes

□ Heavy flow □ Clots □ Pain/Cramping □ Irregular periods □ Discharge
□ Bleeding between periods □ Other________________________________
If menopausal
Age/year began_____________ Any Postmenopausal bleeding? □ No □ Yes

D. PREGNANCY HISTORY

Total No. of Full Term Premature

Abortion Living Multiples
Pregnancies Deliveries Deliveries Deliveries
3 2 2 0 0 2 0

Physician’s
Name/
Baby’ Type of Place Note of
Birth Date Gestation Age RN/RM
s Sex Delivery of Complications of
Mm/DD/YYY #Wks@Delivery (Handled
(M/F) (NSD/CS) Delivery Mother/Newborn
the
delivery
June 7, 2006 F 37 weeks NSD House Midwife None
(Celia Servo)
January 28, 2011 F 38 weeks NSD Clinic Midwife None
(Celia Servo)

E. PAST OBSTETRICAL/GYNECOLOGICAL SURGERIES:

Surgery Mo/Year Reasons
None - -

F. PAST SURGICAL HISTORY:

Disease/Surgery Mo/Year Reasons
None - -
G. BIRTH CONTROL HISTORY
1. Use of Family Planning Method: No Yes
Natural Type: Calendar Method Year Started: 2013 Year Stopped/Reason: 2018
Artificial Type: ____________ Year Started: ________ Year Stopped/Reason: ________

H. PAST MEDICAL HISTORY (include childhood illnesses)

Illness/Disease Mo/Year Reasons
None - -

I. HEALTH HISTORY
Check if
Deceased
Disease with Affected Relatives
(Note age and cause)
History
Diabetes - - -
Heart Disease - - -
Kidney Disease - - -
Blood Disease - - -
Cancer - - -
Asthma - - -
Hypertension - - -
Thyroid Disorder Mother 39 (Grave’s Disease)
Systemic Autoimmune Disease - - -
Multiple Pregnancy (Gestation) - - -
Chromosomal/ Genetic Disorder - - -
Other/Specify - - -

J. MEDICATIONS
Medication Dose Frequency
Before Pregnancy None
During Pregnancy None

K. DRUG/FOOD ALLERGIES None

Allergen Reaction
None -

L. PERSONAL HISTORY
1. Smoking: Never Yes, Packs/Day _____________ Types: _______________
Former Years smoked _____________
2. Alcohol Never Former Yes, Drinks/Week__________ Type: ________
3. Illicit Drug Never Former Yes Type: ____________________________
 4. Caffeine Intake Yes No
Coffee Tea Soda Energy Drink Chocolate
Daily Intake: Twice a week
5. Nutritional Intake:
Usual diet (type): Paleo Diet
Carbohydrate: Low Medium High
Protein: Low Medium High
Fat: Low Medium High
Salt: Low Medium High
# of meals daily: 3 times a day
snacks (number/time consumed): twice a week
Dietary pattern/content:
B: Rice, fruits, Protein foods and Milk
L: Rice and Vegetables
D: Bread and Milk
Snacks: Ice cream

6. Regular Exercise □ No Yes Type: Walking Amt/Wk: 30 meters

M. Physical Examination:
BP: ______ mmHg CR: _____ bpm RR: _____bpm T: ______ °C
Height: 5 Ft Weight: 71 kg
General Appearance: Normal looking Pregnant Woman
Skin: __________________________________________________________________________
Head, EENT: ___________________________________________________________________
Neck, lymph nodes: ______________________________________________________________
Chest, Breast: __________________________________________________________________
Heart: _________________________________________________________________________
Abdomen (Stomach, Liver, Gallbladder, Spleen)________________________________________
Kidney, bladder, ureter ___________________________________________________________
Genitalia_______________________________________________________________________
Spine extremities ________________________________________________________________
Neurological ____________________________________________________________________