Professional Documents
Culture Documents
I. BIOGRAPHIC DATA:
Name: DOA:
Age: Ward:
Nationality: Diagnosis:
G-P-L-A-D
Occupation: L.M.P:
Marital status:
Husband name:
Age:
Education:
Occupation:
Income:
Address:
LMP:
EDD:
No of antenatal visits:
A] First trimester
Nausea---------------
Vomiting------------
Constipation--------------
Giddiness---------------------
Heart Burn--------------------
Burning Micturition-----------------
Pica--------------------
Infections-------------
Leucorrhea------------------
Use of drugs-----------------
Immunization----------------
B] Second Trimester
Quickening--------------------
Burning Micturition--------------
Pedal Edema--------------------
Back Pain-----------------
Puffiness of Faces----------------
Heart Burn-----------------------
Insomnia-------------------------
Vaginal Discharge------------------
C] Third Trimester
Pedal Edema-------------------
Abnormalities----------------
S.n Gravid Gest- Abnormal Mode Abnorma Aliv Sex Bir Healt Breas
o a ationa ity-ties in Of lities in e th h t
/parity l Pregnanc deliver labour Wt statu feedi
age y-y y s ng
V. PAST HEALTH HISTORY
Accidents: -------------------
By whom -----------------------
Dysmenorrhea ----------------------
Yes--------------------
No--------------------------
Treatment---------------------
Hospitalization-----------------
Fallow up------------------------
X. PAST SURGICAL HISTORY:
Yes-------------------------
NO---------------------------
Treatment-----------------------
Hospitalization-----------------
Fallow up------------------------
S.no Name of Relation Sex Age Education occupation Health Handicaped If any
Family To head status Disease
Members cause
FAMILY TREE:
XII. HOME ENVIRONMENT:
Lighting: -----------------
Savings -----------------
Hygiene: -------------
Elimination: ---------------
Habits --------------
24hrs recall:
Activity: dull/active
BMI:
Edema: generalized/localized
Vital signs:
Temperature: ------------
Pulse: ----------------
Respiration: ----------------
Skin:
Colour:
Texture: dry/moist
Head:
Scalp: dandruff/healthy
Eyes:
Symmetrical: yes/no
Eyelids:
Conjunctiva: pale/pink
Discharges:
Squint: yes/no
Ears:
Symmetrical: yes/no
Hearing: yes/no
Nose:
Nostrils: symmetrical/asymmetrical
Discharges: yes/no
Mouth:
Gums: -----------------
Teeth: ---------------
Tongue: ----------------
Lips: -------------------
Odour: ---------------
Neck: -------------
Tonsils: ----------------
Thyroid: enlarged/normal
Trachea: --------------
Range of motion:
Chest:
Extremities:
Polydactyl: yes/no
Amputations:
Polydactyl: yes/no
Amputations:
OBSTETRICAL EXAMINATION
BREAST:
Nipples:
Tenderness: yes/no
ABDOMEN:
INSPECTION
Shape: --------------
Size: ----------
Operational scars:
PALPATION:
Lateral palpation:
Left: -----------------
Right: -------------------
AUSCULTATION:
Location:------------
Rate: ----------
Results: ------------
GENITALIA:
Hymen: -----------------
Perineum: ----------------
Vaginal examination:
INVESTIGATIONS:
Blood group:
HIV: positive/negative
HbsAg: positive/negative
Hcv: positive/negative
TREATMENT:
NURSING DIAGNOSIS:
HEALTH EDUCATION: