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Comprehensive ANC Assessment Form

This document contains an ANC assessment form with the following sections: 1. Sociodemographic and personal information including name, age, address, family details, income, religion, diet, and medical history. 2. Medical history seeking any illnesses, allergies, or conditions during or prior to pregnancy. 3. Surgical history and any prior procedures or blood transfusions. 4. Family history of illnesses. 5. Menstrual and obstetric history including prior pregnancies, deliveries, and health of living children. 6. Current family planning methods and intentions after delivery. 7. Requested investigations including blood groups, HIV status, HBs

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109 views5 pages

Comprehensive ANC Assessment Form

This document contains an ANC assessment form with the following sections: 1. Sociodemographic and personal information including name, age, address, family details, income, religion, diet, and medical history. 2. Medical history seeking any illnesses, allergies, or conditions during or prior to pregnancy. 3. Surgical history and any prior procedures or blood transfusions. 4. Family history of illnesses. 5. Menstrual and obstetric history including prior pregnancies, deliveries, and health of living children. 6. Current family planning methods and intentions after delivery. 7. Requested investigations including blood groups, HIV status, HBs

Uploaded by

raut9657991617
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

ANC ASSESSMENT

●PERSONAL PROFILE
Name:-

Age:-

Sex:-

Father Name:-

Mother Name:-

Grade/ Class:-

Completed by:-
Date of Assessment:-
A) Sociodemographic And Personal Information: -

▪Name:-

▪Age :-

▪Address:-

▪ Mobile no :-

▪How far are the various health care setting –


eg. Government Hospital, Primary health Centre, Subcenter or Private
clinic?

▪Number of family member:-


▪Types of family :-

▪Total income of family:-

▪Per Capital:-

▪Religion:-

▪Mother tongue:-

▪Husband Name & Age :-

▪Education of mother and her husband:-

▪Dietary habits:-
▫Does the mother have PICA.

▫Does the mother smokes take any drugs, alcohol, etc.

▫Any culture and Religion beliefs regarding pregnancy, delivery, new


born.

B) Medical History:-
▪Ask for any major illness. E.g. Allergies, jaundice, malaria, STD/RIT,
diabetes, hypertension, hypo/hyperthyroidism, tuberculosis, anemia, worm
inflectation, Rubella, etc. in the post or during pregnancy.

▫When did it start?

▫Does the problem still persist?

▫Is any medicine being taken for the problem?


C) Surgical History:-
▪Ask for any surgery performed and subsequently verify the available record
and see for any surgical scar-

▪Ask for any blood transfusion received reason for transfusion and donor.

▪STD- Sexual Transmitted Disease.


▪PICA-Bad habits

▪RTI- Reproductive tract infection.

D) Family History:-
▪Ask for any illness in the family like diabetes, hypertension, etc.

▪Ask for any birth of twins/ multiple pregnancies in any family member.

▪Ask for any genetic disorder in the family members.

E) Menstrual History:- (before pregnancy)


▪Age at puberty.

▪Average duration of menstrual cycle.

▪Amount of blood loss during menstruation.

▪Any problem due to menstruation.

F) Obstetrical History:-
▪After delivery mother & child care-

▪Ask about previous pregnancies any problems experienced.


▪Ask for the intranatal & postnatal progress of the previous pregnancies.

▪Ask for the place of delivery of these pregnancy.

▪Enquire for the living children & their current health status as per the table
below-

Sr/no Year of POG at Type of Puerperium


delivery Time of delivery
Abortion delivery

▪ Status of Baby:-

Status at Sex Wt.205kg/ Present


normal weight Condition

LBW- low birth weight baby-

POG-Period of a gestation-

G) Family Planning-
▪Have you adopted a family planning method?

▪which method was adopted?

▪For how long did you use it?


▪why was it discontinued?

▪Have you ever had a side effect of that method?

▪Will you adopt any family planning method after delivery?

▪Which method you will adopt and why?

H) Investigation & Report:-


▪Blood group of the mother & her husband

▪Rh- factor- +,-, antigen antibody of the mother & her husband

▪UDRL of the mother & her husband

▪HIV status of the mother & her husband human Immunodeficiency disease.

▪Hbs Ag of the mother & her husband

▪Hb level on

▪Urine sugars & Albumin

▪Blood sugar

▪Glucose Tolerance Test (GTT)

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