PRENATAL RECORD

PATIENT INFORMATION

NAME: _________________________ AGE: ______ MIDDLE INITIAL:______

ADDRESS: ______________________OCCUPATION:____________________

HUSBAND’S NAME: ____________________________ AGE: _____________

OBSTETRIC HISTORY
GRAVIDA: TERM: ABORTION: PARA: LIVING:

LMP: FUNDAL HEIGHT: EDC: WEIGHT:

POSITION: ENGAGE: FLOATING:

VITAL SIGNS
TEMPERATURE: BP: PULSE: RESPIRATION:
IMMUNIZATION
TT1: TT2: TT3: TT4: TT5:
OPERATION
CS: APPENDECTOMY: HERNIA: OTHERS: NONE:

PRENATAL RECORD
PATIENT INFORMATION
MRS. MYRNA
NAME: _________________________ -
40 MIDDLE INITIAL:______
AGE: ______
MOHON, TALISAY CITY, CEBU NONE - HOUSEWIFE
ADDRESS: ______________________OCCUPATION:____________________
MR. JOSEPH
HUSBAND’S NAME: ____________________________ AGE: _____________ 50

OBSTETRIC HISTORY
GRAVIDA: 4 TERM: 3 ABORTION: 0 PARA: 3 LIVING: 3

LMP: 10-05-2013 FUNDAL HEIGHT: 32cm EDC: 07-12-2014 WEIGHT: 53 kg

POSITION: TRANSVERSE ENGAGE: FLOATING: ✓

VITAL SIGNS
TEMPERATURE: 37.2 BP: 130/70 mmHg PULSE: 85 bpm RESPIRATION: 21 cpm
IMMUNIZATION
TT1: TT2: TT3: ✓ TT4: TT5:
OPERATION
CS: APPENDECTOMY: HERNIA: OTHERS: NONE: ✓

PRENATAL RECORD
PATIENT INFORMATION
MRS. DELIA
NAME: _________________________ -
46 MIDDLE INITIAL:______
AGE: ______
DAM, CARCAR CITY, CEBU JANITRESS
ADDRESS: ______________________OCCUPATION:____________________
MR. RENE
HUSBAND’S NAME: ____________________________ 48
AGE: _____________

OBSTETRIC HISTORY
GRAVIDA: 8 TERM: 8 ABORTION: 0 PARA: 7 LIVING: 7
LMP: 09-07-2014 FUNDAL HEIGHT: 32 cm EDC: 06-14-2015 WEIGHT: 55 kg

POSITION: TRANSVERSE ENGAGE: FLOATING: ✓

VITAL SIGNS
TEMPERATURE: 37.5 BP: 130/90 mmHg PULSE: 88 bpm RESPIRATION: 18 cpm
IMMUNIZATION
TT1: TT2: TT3: TT4: TT5: ✓
OPERATION
CS: APPENDECTOMY: HERNIA: OTHERS: NONE: ✓