Done by: Aiman Al-Sharabi, Group 5, Batch 33, Division of Medicine, Faculty of M. & H. S.

, Sana'a University
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 PERSONAL HISTORY
Quadruple Name: ……………………………………………………………………………………………………………………… Age: …………………………
Marital Status: □ Married □ Widow □ Divorced; for ………………………… years.
Number of Children: …………………………
Occupation: ……………………………………………………
Address: from ……………………………………………………, living in ……………………………………………………
Special Bad Habits of Medical Importance: □ Smoking □ Chewing Qat □ Others: ……………………………………………………
Blood Group: …………………………….…… Telephone Number: ……………………………………………………

 CHIEF COMPLAIN
She is pregnant in the ………………………… month,
coming for: ………………………………………………………………………………………………………………………………………………………………………..,
or complaining of: ………………………………………………………………………………………………………………………………………………………………

 PRESENT HISTORY
She is pregnant (GA) …………… weeks and …………… days, as evident by the 1st day of LMP on …………………………, so the EDD
is …………………………
She was admitted on …………………………………………………… at …………………………
 Analysis of Chief Complain:
Pain Bleeding Discharge
□ Sudden □ Sudden (acute) Duration ……………………...
Onset □ Gradual Onset □ Gradual □ Odorless
Odor
□ Insidious □ Insidious (chronic) □ Offensive
□ Regressive □ Psychological Trauma □ Scanty
□ Stationary □ IUD Insertion Amount □ Average
Preceding
Course □ Progressive □ Horm. Contraception □ Excessive
Event
□ Intermittent □ Amenorrhea □ Watery
□ Others: …………………… Consistency
□ Continuous □ Viscid
Duration …………………….. Duration …………………………….……. Color ……………………...
Site …………………….. □ Regressive □ Itching
□ Stationary Associated
□ Colicky □ Swelling
□ Progressive Symptoms
□ Heaviness Course □ Pain
□ Burning □ Intermittent
Type or
□ Stitching □ Continuous
Character
□ Stabbing □ Scanty or Spotting
□ Throbbing Amount □ Average
□ Dull aching □ Excessive
□ Mild Number of ……………………………………
Severity □ Moderate Pads/Diapers ………………….……………….
□ Severe □ Yes
Blood Clots
Radiation ……………..…….. □ No
Aggravating F. …………….….….. □ Fresh bright red
Color
Relieving F. ..………………….. □ Dark red
□ Bleeding □ Pain
Associated Associated
□ Discharge □ Discharge
Symptoms Symptoms
□ Swelling □ Swelling

- Others: ………………………………………………………………………………………………………………………………………………………………….
- Seek of Medical Advice and Hospitalization: ………………………………………………………………………………………………………..
- Management: ……………………………………………………………………………………………………………………………………………………….
  Retrograde Analysis of Pregnancy:
- Consultation before Pregnancy: □ Planned □ Unplanned.
- Pregnancy is discovered by: □ Miss-period (amenorrhea) □ Nausea & Vomiting □ Others: …………………….………
- Pregnancy is Confirmed by: □ Pregnancy Test □ Ultra-Sound □ Others: ……………………………………………………….…
- 1st Trimester:
□ Nausea & Vomiting □ Abdominal Pain □ Vaginal Bleeding □ Cough □ Dysuria □ UTI
□ Frequency of Urination □ Hospitalization □ Others: ……………………………………………………
- 2nd Trimester:
□ First Quickening/Fetal Movement was in …………………………, since that time it is about …………… times per day.
□ Nausea & Vomiting □ Abdominal Pain □ Vaginal Bleeding □ Cough □ Dysuria □ UTI
□ Frequent Urination □ Hospitalization □ Others: ……………………………………………………
- 3rd Trimester (History of Warning Symptoms of Pregnancy):
□ Nausea & Vomiting □ Abdominal Pain □ Vaginal Bleeding □ Vaginal Discharge □ Lower Limb Edema
□ Diminished Fetal Movement □ Blurring of Vision □ Headache □ Others: …………………………………………………
 ANC:
- Getting ANC: ………………………………………………………………………………………………………………………………….……………………….
- Regularity: □ Regular □ Irregular.
- Outcomes: ………………………………………………………………………………………………………………………………………..…………………….
 Review of Other Systems:
- General Symptoms:
□ Fever □ Loss of Weight □ Night Sweating □ Loss of Appetite. □ Other: ………………………………………………….
- Cardiovascular System:
□ Chest Pain □ Cyanosis □ Palpitation □ Edema. □ Other: …………………………………………………………………………
- Respiratory System:
□ Dyspnea □ Cough □ Sputum □ Hemoptysis □ Wheezing. □ Other: …………………………………………………....
- Gastrointestinal Tract:
□ Dysphagia □ Epigastric Pain □ Diarrhea □ Constipation □ Rectal Bleeding. □ Other: ………………………….
- Renal System:
□ Dysuria □ Frequency □ Urgency □ Hesitancy □ Retention □ Suprapubic Pain □ Other: …………………..
- Central Nervous System:
□ Headache □ Blurring of Vision □ Syncope □ Convulsions □ Tinnitus □ Vertigo □ Dizziness
□ Loss of Memory □ Muscle Weakness □ Paralysis. □ Other: ……………………………………………………………………….
- Musculoskeletal System:
□ Joint Pain □ Bone Pain □ Weakness □ Stiffness □ Paralysis. □ Other: ………………………………………………...
- Endocrine System:
□ Polydipsia □ Polyuria □ Polyphagia □ Heat Intolerance □ Cold Intolerance. □ Other: …………………………
- Hematological System:
□ Easy Fatigability □ Melena □ Skin Rash □ Petechiae □ Ecchymosis □ Epistaxis. □ Other: ………………..

 MENSTRUAL HISTORY
Age of Menarche: ………………………… years.
Rhythm of Menses: □ Regular (within one week before or after expected time) □ Irregular.
Menstrual Cycle Length: ………………………… days.
Menstrual Period Length: ………………………… days.
Amount of Menstrual Blood Loss/Flow (by asking about number of pads or diapers per day or presence of blood clots):
□ Scanty □ Average □ Excessive.
Intermenstrual Pain (Mettleschmerz): ……………………………………………………………………………………………………………………………….
Intermenstrual Bleeding (Ovulatory Spotting): ………………………………………………………………………………………………………………….
Intermenstrual Discharge (Ovulatory Cascade): …………………………………………………………………………………………………………………
Associated Symptoms (e.g. Dysmenorrhea, i.e. pain related to menstruation):
□ 1ry Spasmodic (colicky pain with onset of menstruation) □ 2ry Congestive (dull aching pain before menstruation).
 OBSTETRIC HISTORY
 Gravidity & Parity:
- Gravida …………………………, Para ………………………… + …………………………
- Number of Living: …………………………, Males …………………………, Females …………………………
- The youngest age …………………………, The oldest age …………………………
 Past Obstetric History:
Mode of ♂ Postpartum Puerperium
Date Duration Course ANC Place Lactation
Termination ♀ Complications Complications
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
 Contraception History:
- Use: □ Yes □ No.
- Method: □ Pills □ Injections □ Implants □ IUD □ condoms □ Tubal Ligation □ Others: …………………..
- Duration: …………………………………………………….…………………………………………………….…………………………………………………..
- Complications: …………………………………………………….…………………………………………………….…………………………………………..

 PAST HISTORY
Past Medical Disorders: □ Hypertension □ Diabetes □ Heart Disease □ Others: …………………………………………………….
Past Gynecological Disorders: …………………………………………………….…………………………………………………….……………………………….
Past Surgical Operations: …………………………………………………….………………………..………………………………….……………………………….
Past Blood Transfusions: …………………………………………………….…………………………………………………………….……………………………….
Past Exposure to Irradiation: ……………………………………..……….…………………………………………………………….……………………………….
Drugs Hypersensitivity or Food Allergy: …………………………………………………………………………..……………….……………………………….

 FAMILY HISTORY
Medical Disorders among Family Members: □ Hypertension □ Diabetes □ Heart Disease □ Others: ……………………
Twins Pregnancy among Family Members: …………………………………………………….……………………………………………..………………….
Congenital Fetal Anomalies among Family Members: …………………………..……….……………………………………………..………………….
Positive Consanguinity between Wife & Husband: …………………………………………………….……………………………………………..….….

 SOCIOECONOMIC HISTORY
Electrical Supply: ……………………………………………..……………………, Water Supply: ………………………..………………………………………..
Income: ………………………………………………..………………..……………, House: ….…………………………….………………………..……………………
Husband:
- Name: ………………………………………………………………………………………………………………………, Age: ………………….………………
- Occupation: …………………………………………………………………………………………………………………………………………….……….......
- Special Habits of Medical Importance: □ Smoking □ Chewing Qat □ Others: …………………………………….…………...

 SUMMARY
Quadruple Name: ……………………………………………………………………………………………………………………… Age: …………………….………
She is Gravida: …………………………, Para: ………………………… + …………………………, with GA: …………… weeks.
Complaining of: …………………………………………………………………………………………………………………………………………………………….……
Medical Interventions: …………………………………………………………………………………………………………………………………………………….…
Its Outcomes: ……………………………………………………………………………………………………………………………………………………………………..