NEONATAL INTERVIEW

GENERAL DATA:
Time of interview: 11:22 AM
Room:
Data & Time of Admission: October 25, 2020
Obstetrician/ Pediatrician:
Patient’s Name:
Date & Time of Delivery:
Birthplace: St. Paul’s Hospital
Age:
Sex:
Religion:
Race/Nationality:
Blood type:
Present Address:
Informant’s Name:
Informant’s relationship to the patient:
Reliability:

HISTORY OF PRESENT ILLNESS

Gestational History

Mother: Janell Yap Banes

Age:
Age during pregnancy:
Civil status:
Educational Status:)
Occupation
Blood type:

Father’s Name:
Age:
Civil status:
Educational Status:
Occupation:
Blood type:

Planned Pregnancy/Wanted:
Known diseases? HPN, DM, Asthma, Allergies, etc.:
RT-PCR Result:
Baby results:
OB History

OB Score: G2P2 (2-0-0-2)

 G1 Dec. 19, 2016 St. Paul’s No
Hospital Complications

G2 Oct. 22, 2021 St. Paul’s

Hospital

LMP: Jan. 25, 2021

EDD: October 25, 2021

Prenatal History

Pre-Natal Check-ups:
Date if 1st prenatal:
AOG of first prenatal visit:
Total # of prenatal visits:
Number of ultrasound exposures and results:
No infection, uti , no increase BP.

On each pre-natal visit:

HBsAg status:
Laboratory tests requested and results:
Medications and compliance:
Vaccinations:
Pregnancy complications and management:
Height & Weight:
Exposure to infection radiation, medications, drug use, alcohol, smoke:

Present Pregnancy

Age of the baby during delivery:

Type of delivery:
Duration of the delivery:
Complications:

Birth history

Sex, term/preterm/post-term, AOG, birth weight, AGA/SGA/LGA, fetal presentation, via

NSVD/Primary CS (specify indications for CS), APGAR score, +/- cord coil, +/- meconium stain
Complications: infant of gestational diabetic mother IR/NIR, etc.

Postnatal history

Routine newborn care done:

Urine output and bowel movement:
Quality of cry, motor activity and tone:
Vaccination received:

Feeding History

Type of feeding:
How many times per day:
How long each breast:
Difficulty in feeding:

Immunization History

Vaccinations:

Family History
Diseases of both parents and other family members:
Sexual history:

Personal, Social and Environment History

Living circumstances:
Place and nature of dwelling
Number of persons living with:
COVID Exposure:
Economic circumstances:
Exposure to cigarette smoke and pollutants:
Garbage disposal:
Sewage disposal:
Water source: