Personal Data

• Name : • Husband’s name.

• Age . • Husband’s age.

• Occupation. • Occupation.

• Residence. • Level of education.

• Blood grouping.
• Level of education.
• Consanguinity.
• Marital status.

• Duration of marriage.

• History of the present illness (complaint)

• DURATION

• ONSET

• Systemic enquiry
• Gravidity:
• Parity: after 24
• +…. abortion before 24 week’s:
Obstetrical history The past pregnancies
- Duration :
- Complications during pregnancy :
- Onset of labor :
- Duration of labour :
- Mode of delivery:
- Place of delivery:
- Complications after delivery (retained placenta, PPH, DVT, UTI, psychosis, anaemia…etc).
• Outcome of the pregnancy:
1. - Newborn weight
2. - Condition of the newborn (alive/dead, cried immediately, taken to N.I.C.U.
3. - Breast-feeding / Bottle-feeding.
4. - Age of the baby now / Milestones.
• In case of caesarean section you have to ask about:
- Elective/emergency.
- Cause of C/S.
- Blood transfusion.
- Complications
- Stay in hospital.
• In case of stillbirth you have to ask about:
- Fresh/macerated.
- Cause(S): HTN, DM, PROM, prematurity..etc
- Weight of the baby.
- Malformations.
- Mode of delivery.
• In case of abortion you have to ask about:
- Gestational age.
- Spontaneous or induced.
- Evacuated or not.
- Blood transfusion.
- Complications: bleeding, perforation,infection.
- Possible cause(s).
• History of current pregnancy :
– LMP) The first day of the last menstrual period :
▪ (EDD) :
▪ calculate the gestational age (in weeks).
Also ask about:
- When pregnancy test was done?.
- When the first ultrasound was done?.
- When the first fetal movement (quickening).
• Then ask questions by trimester:
- In the first trimester ask about nausea, vomiting, bleeding and folic acid supplimentation.
- In the second trimester ask about the above questions + the use of iron and calcium, vaccination,
fetal quickening, ultrasound, vaginal bleeding, antenatal visits.
- In the third trimester ask about: fetal growth and movement, any complication during this
pregnancy (bleeding, hypertension, anaemia…etc).

- Name.
- Age.
- G…P…+…
- Mode of delivery of previous deliveries.
- Gestational age.
- Cause of admission or complaint.

Example: this is Mrs. X, aged 28 years, G 4 P 2 + 1 all of them SNVD

at 30 week’s gestation and she came to the hospital with of
reduced fetal movements/labour pain
• Gynaecological history
• AGE OF Menarche.
• Kata. 5/28. ‫عدد أيام الحيض‬
• The cycle:
❖Pattern.
❖Amount.
❖Associated pain.
❖Vaginal discharge (colour, amount, consistency, odour,
itching)
❑Use of contraceptives.
❑history of pap smear and mammography
❑Sexual history
• Gynaecological surgery
❑ Past medical and surgical history
➢ Hypertension.
➢ Diabetes.
➢ Asthma.
➢ Hospitalization.
➢ Blood transfusion
➢ Epilepsy
➢ HIV
➢ Venous thromboembolic disease (↑risk of Thromboembolism, pre-eclampsia, FGR)
➢ Connective tissue diseases (SLE) (↑risk of pre-eclampsia, FGR)
- Type of operation including gynaecological operation (D&C , myomectomy… etc),
date and complication(s).
- Type of anesthesia used and complication(s).
❑ Family history
– Hypertension,
– diabetes,
– asthma.
– Twin pregnancy.
– Congenital malformations/handicaps.
– Anaemia
– Cardiac disease.
❑ Drug history:
• Regular use of medication (chronic use).
• Allergy to any drug specially penicillin.
• Pre-conceptual or early use of folic acid.
• Current use of medication.

❑ Social history:
• Housing condition.

• Abnormal habit e,g smoking