IBEROAMERICAN UNIVERSITY CENTER FOR PROFESSIONAL STUDIES

Bachelor's degree in nutrition

Pregnant woman file

Student: Diana Mejía Ramírez

Subject: Evaluation of Nutritional Status

LN Alejandra García Bárcena

Date:

GENERAL DATA

Patient's name:

Age: _______years Sex: (F) Date of birth:

____________

Marital Status: _______________Schooling:

____________________________

Address:
___________________________________________________

Phone: _____________________________________________

E-mail:
___________________________________________________

Occupation: __________________ Working hours:

____________________________ Type of work
(subordinate, independent, nocturnal or dangerous)
___________________________________________________
Meal times: ____________________ Religion:
______________________________

Reason for consultation:

MEDICAL HISTORY

History of health/illness

Current problems

Diarrhea: ( ) Constipation: ( ) Gastritis: ( ) Ulcer: ( )

Nausea: ( ) Pyrosis: ( )

Vomiting: () Headache: ( ) Colitis: ( )

Clinical signs

Interpretation of signs related to deficiencies:

General appearance (hair, eyes, skin, nails, lips, gums, etc.).

Remarks

Have had any illness diagnosed in the last 6 months:

___________________________________________________

Which:_____________________________________________

Has suffered from any major, pathological or chronic illness:

___________________________________________________
Which:
___________________________________________________

Chemotherapy: _________________________ Radiotherapy:

______________________________________

Take any medication __________Which:

___________________________

Dose_______________________ Since when

___________________________

You have undergone surgery: ____________

Type (intervention/aesthetic): ___________________ How

long ago: ____________________________________

He is under treatment: ________ What it is about:

___________________________

Here:

Laxatives ( ) Diuretics ( ) Antacids ( ) Occasional

analgesics ( )

Which: ______________________________ For how long:

_____________________________________

Family history

Obesity: ( ) Diabetes: ( ) HTA: ( ) Cancer: ( )

Dyslipidemias: ( ) LCA: ( )

Gynecological aspects

At what age did you start your sex life? ___________________

The period was presented on a regular basis: ________

Approximate duration of your last period:
___________________________________________________

Was your last period normal (no bleeding less or more than
usual)?

Use of contraceptives: YES □ NO □

Which one?
___________________________________________________

Dose
___________________________________________________

Time: _____________________________

You have side effects: ________________

Which:

SDG (Weeks of gestation):

___________________________________________________

LMP (date of onset of last menstrual period)

___________________________________________________

It's your first pregnancy: ________

Established due date: ________________________

He has children: ___ How many?___________ Natural

childbirth: ________ Cesarean section: ______

Ages: ________________________________

SOP: YES □ NO □ □
Hypothyroidism: YES □ NO □

How long ago: ________________________

Hormone Replacement Therapy: YES □ NO □

Which one?
___________________________________________________

Dose
___________________________________________________

You are constantly getting a Pap smear:

___________________________________________________

Date of last checkup:

___________________________________________________

She has all doses of human papillomavirus:

___________________________________________________

Had problems with a previous pregnancy or childbirth YES □

NO □

Which:

You have been feeling very tired or weak: ___

Elevation in blood pressure levels:

She has previously suffered from preeclampsia:

___________________________________________________

You have had seizures (fits) during your previous pregnancies

or during this pregnancy:

Screening for gestational diabetes:_______________

Was your last delivery prolonged or did you have to push for a
long time?
___________________________________________________

Did you have a fistula?____________

The delivery was early: _______

Whereas:
___________________________________________________

Weight of last baby: ______________

Measurements of the last baby: _____

• She gave birth to a very small baby (less than 5 pounds).

• She had a very large baby (over 9 pounds).

Did you bleed a lot before or after delivery?

Some problem related to the placenta:

Presence of fever or any infection of the womb during or after

delivery:
___________________________________________________

Postpartum mood:
___________________________________________________

Have you had any abortion: YES( ) NO( )

Reason:

Your baby had a congenital malformation:

Attends with the gynecologist: ____________

Any recommended supplementation: YES ( ) NO ( )

Which:
___________________________________________________

SOCIOCULTURAL HISTORY

Socio-cultural aspects

With whom you live:

___________________________________________________

Who is in charge of household chores:

___________________________________________________

Economic factors

Income determined for food:

___________________________________________________

Access to food:
___________________________________________________

Emotional factors

Family death: ______________Loss of employment:

_________________________ Love breakup:
_________________________

Daily stress level: ____________________

Cultural and religious factors

Foods not allowed:

Rituals:

Meat YES □ NO □ Eggs YES □ NO □ Fish YES □ NO □

Alcohol YES □ NO □ NO □
Others:
___________________________________________________

GENERAL DATA......................................................................................................
SIGNS.......................................................................................................................

LIFESTYLE

Exercise

Type_________________________Frequency
_____________________________

Duration ______________________When did it start?

_____________________________

Activity:

Very light ( ) Light ( ) Moderate ( ) Heavy ( )

Exceptional ( )

Consumption of harmful or toxic substances (frequency and

quantity):

Alcohol: ( )

Frequency:___________

Quantity:____________

GENERAL DATA......................................................................................................
SIGNS.......................................................................................................................

Frequency:___________

Quantity:____________
Weekend

When does your weekend start? _____________

What do you usually consume?

Dietary indicators

How many meals per day: _____________

Meals at home Meals out Meal times

Weekdays

Weekend

Who prepares your food? ________________________

Do you eat between meals? ___What? _______________________________________________

How often you consume water: ____________________________________________________

How many liters? __________

You have changed your diet in the last few months

YES ( ) NO (______________________________) Why

How to

Frequency: ____________________________________________________________________

Frequent cravings: ________________

What kind of cravings?

Frequent ascites: ___________

How often do you go to the bathroom? ______

How many micturitions

(pipi)________

(poop)_______

Do you find it difficult to use the toilet? _____________________________________________

Appetite: Good: ( ) Bad: ( ) Regular: ( )

What time are you usually hungriest? _______________________________________________

Preferred foods:

Foods you do not like / are not used to:

Do you take any supplement/supplement: Yes ( ) No (_____________________________)

Which:
Dosage: _________Why __________________________________________________________

Are you allergic or intolerant to any food: Yes ( ) No ( )

Your consumption varies when you are sad, nervous or anxious: Yes ( ) No ( )

How:

Add salt to the food already prepared: Yes ( ) No ( )

What fat do you use at home to prepare your food?

Margarine Vegetable oil Lard Butter Others __________________________________________

Have you previously attended a nutritionist___

Reason: _______________________________________________________________________

You had the expected results: __________ Have you been on a special diet? ________________

How many? ______ What type of diet? ______________________________________________

How long ago? _________________________________________________________________

For how long? ___________________For what reason? _________________________________

How attached to it? _______________ Did you obtain the expected results? _________________

Have you used weight-loss medications YES ( ) NO ( ) Which _____________________

 USUAL DIET

Breakfast

Glasses of natural
Collation water per day: ______

Glasses of liquids per

day:_________
Food

Collation

Dinner

Collation
ANTHROPOMETRIC EVALUATION
MEASUREMENT DATO

Weight

Height

Hip circumference

Circumference of abdomen

Waist circumference

SIGNS

Blood pressure (range 120-80): ________________

Time: ___________________

Arm: ___________________

Temperature: ___________________

Fist heart rate: __________________________

Respiratory frequency: ____________________