SOCIAL SECURITY SYSTEM

MEDICAL EVALUATION RECEIVING CENTER

BAGUIO BRANCH

Name: ____________________
SSS #: ____________________ Date: ___________

COMPLETE OBSTETRICAL HISTORY

(To be filled up by attending OB –Gynecologist)

A. OBSTETRICAL SCORE: _______________________

B. DETAILED OB – HISTORY (Complete data below using the format)

G1 = ___________ _______________________
Date Type of Delivery

G2 = ___________ _______________________
Date Type of Delivery

G3 = ___________ _______________________
Date Type of Delivery

G4 = ___________ _______________________
Date Type of Delivery

C. OTHER REMARKS (if any)

Note: This serves as member’s Medical Certificate.

___________________________
Printed Name and Signature
Attending OB – GYNE

PRC Lic. #: _______________

Clinic/ Hospital Address

_________________________
_________________________