OBSTETRIC FORM

OBSTETRIC FORM

Date of Examination: Time:

I. BIOGRAPHIC DATA
Name: Charina Caparida
Address: 162-C katipunan Street Labangon Cebu City
Date of Birth: December 5, Age: 46 Place of Birth: Toledo City Blood Type:
1978
Civil Status: Nationality: Religion:
Husband’s Name: Occupation:
Address:

II. OBSTETRICAL HISTORY

No. of children born alive: Illness during previous pregnancies:(please put a check
mark)
No. Of living children: None GDM PIH
No. of abortion Hyperemesis H-mole Asthma
No. Of stillbirths or fetal UTI Tuberculosis Hepatitis
deaths: Goiter Others:
History of large babies: (8lbs
& above):
Date of Last Delivery:
Type of Last Delivery: Previous Hospitalization
(Please Check)
NSVD C-Section Forceps/Vacuum Extraction
(Indication)

III. PRESENT PREGNANCY

Menarche: Last Menstrual Period: Obstetric Score:
G_T_P_A_L_M_
Birth Rank: Expected Date of Delivery: Age of Gestation:
Fundal Height: PLAN OF DELIVERY
Plan to submit baby to Where to Deliver:
Newborn Screening: To be attended by:
Yes No
 IV. MEDICAL HISTORY
Allergies: Tapes Iodine Latex No Known Allergies
Drugs Current
Food Medication Taken:
Environmental
Blood Reaction
Others

Childhood Illnesses:
Previous Hospitalization (Illness, accident, injury, surgery, blood transfusion):

Family Health History:

YES NO Member of the Family

*Heart Disease
*Hypertension
*Stroke
*Tuberculosis
*Diabetes Mellitus
*Cancer
*Kidney Disease
*Blood Disorder
*Asthma

Genogram:

V. Lifestyle
No Yes
*Alcohol Use Frequency:
*Drug Use Type:
*Tobacco Use No.of packs/day:
*Use of Contraceptives Type: Length of Usage:
*Physical Environment:
*Hobbies & Leisure activities
*Economic Status:
PHYSICAL ASSESSMENT (ANTEPARTUM)

A. CARDINAL SIGNS
Blood Pressure: Temperature: Respiratory Rate:
Pulse rate: Height: Weight:

B. SKIN, HAIR, and NAILS

*Color
*Condition
*Lesions
*Moles
*Pigmentation
C. Nose
*Nasal Mucusa
D. Mouth
E. Neck
*Nodes
*Thyroid
F. Chest and Lungs
*Chest
*Ribs
*Breath Sounds
G. Breasts
*Color
*Vascularity
*Thickening and Enema
*Size and Symmetry
*Contour
*Lesions and Masses
H. Heart
I. Abdomen
*Striae
*Fundal Height
*Diastasis of rectus muscle
*Fetal Heart Beat
*Fetal Movement
*Ballotement
J. Extremities
K. Spine
L. Pelvic Area
*External Genitalia
*Vagina
*Cervix
*Uterus
*Ovaries

M. Laboratory Evaluation Patient’s Result

Blood Type
Complete Blood Count
Urinalysis
Capillary Blood Glucose
OGTT
HBSAg

Obstetrical Abdominal Palpation (Leopold’s Maneuver)

Maneuver 1
Maneuver 2
Maneuver 3
Maneuver 4

REMARKS:

CRITERIA:

*Completeness (30) :
*Conciseness (30):
*Factual (30):
*Promptness (5):
*Neatness (5):
Total (100):

Name of Student Year and Section

Clinical Instructor Date of Examination