PATIENT Civil Status:

First Name: Religion:

Middle: Birthplace:
Last Name: Address:
Date of Birth: Contact Number:
Age:
SPOUSE
First Name: Relation to patient:
Middle: Address:
Last Name: Contact Number:
OB-GYN HISTORY
LMP: (unang araw ng huling regla)

EDC: (expected date of delivery)

AOG by LMP: (kung ilang lingo na ang baby sa tummy)

AOG by UTZ: (kelan nagpaultrasound, ilang weeks na si baby by ultrasound)

Birthplan: (saan balak umanak)

OB SCORE
Gravida (ilang beses na nagbuntis):
Para (ilang beses nangangak):
Term (37 week up) term sa loob ng tyan:
Premature:
Abortion:
Living (ilan ang nabubuhay):
PREGNANCY HISTORY
length
Posterm (42 weeks and above) Term (37 – 41 and 6 days)
Pre-term (37 weeks and below) Abortion (20 weeks and below)
Mode
Nsd (normal spontaneous delivery) CS (cesarian)
AVD (assisted vaginal delivery, tinurukan para humilab, painless)
VBAC (gumamit ng aparato like vaccum)
Complication (like post- partum bleeding, 1st 2nd 3rd degree tear, convulsion, hypertension, diabetes,
stillbirth)
List ng mga anak (date of delivery; kung paano inanak; place of birth; complication)

GYN HISTORY
Menarche (ilan taon unang nagkaregla)
Menstrual history (interval, duration, how many pads per day, pain when in mens)
History of contraception used (pills, condom, injectable, implant)

MEDICAL HISTORY
Past medical history: highblood, diabetes, cancer, asthma
Medicine intake:
Allery:
Family history: highblood, diabetes, asthma,
SOCIAL HISTORY
Smoke: Alcohol:
LABORATORY

PHYSICAL EXAMINATION ASSESSMENT

BP: PR:
RR: TEMP:
Height: Weight:
Behavior in history taking:
Fundic height: (sukat ng tyan)
Fetal heart tone:
EENT: (kulay ng schlera or skin ng mata sa loob) pale, pink, yellow)
Lungs sound: (cbs: clear breath sound)
Heart sound: (no murmur)
Extremities: (edema: panas)
VACCINATION HISTORY
TD (tetanus deteria)
MEDICATION
Ferrous sulfate
Calcium chloride