MISAMIS ORIENTAL INSTITUTE OF SCIENCE AND TECHNOLOGY

Cogon, Balingasag Misamis Oriental

SCHOOL OF MIDWIFERY

PRENATAL ASSESSMENT TOOL

Part 1: Demographic Data:

Name:______________________ ________ Age: _____________
Address: ___________________________ Date of Birth: ___________
Educational Attainment: _______________ Religion: _________________
Occupation: ________________________ Date of Interview: ___________
Reason for Visiting the Heath Center: __________________

Part 2: Vital Sign:

Blood Pressure: ________ Pulse Rate: _ _ _ _ _ Respiratory Rate: ______
Temperature: ________ Height: _______

Weight: ____

Part 3: Health History

Present Health Problems: (please encircle)
Tuberculosis (14 days cough) YES NO
Heart Disease YES NO
Diabetes YES NO
Bronchial Asthma YES NO
Goiter YES NO

Past Health History: (Any previous illnesses other than those listed above/hospitalizations/allergies?)
_________________________________________________________________

Family History: (Health of parents, siblings, spouse. Include factors such as cancer, or kidney
diseases, diabetes mellitus, asthma, hypertension and mental illness)

Part 4: Functional Health History

Physical Description of patient’s general appearance, hygiene, grooming, signs of distress,

physical capabilities:
 Mental check orientation to time, place, person. Description of patient’s functioning,
educational status, ability to answer questions, level of understanding.

Emotional description of client’s emotional status. Attitude towards pregnancy including

concerns/feelings:

Spiritual description of patient’s spiritual life, number of times she goes to church, religious
organization affiliation. Religious beliefs and practices regarding diet, birth and blood
transfusion.

Part 5: Gynecologic History:

Age of Menarche: Duration of Menstrual Cycle:
Menstrual Problems present:
Describe any pain:

Part 6: Gynecologic Examination Performed:

Is client practicing Breast Self-Exam? ____
Reproductive Planning Method used: ____
Past Surgery/ies of reproductive system: ________

Part 7: Obstetrical History

Date of Last Menstrual Period: _______________
Expected date of confinement: _______________
Gravida: ___ Term: Preterm: _ Abortion: Livebirth:
Stillbirth: _ Presence of Multiple Gestation:
Birth interval of current to immediate past pregnancy: _

Please check to indicate findings:

YES NO
Previous Caesarean Section
3 Consecutive Miscarriages
Stillbirth
Post-partum Hemorrhage

Part 8: Maternal Discomforts ever Experienced during Present Pregnancy

 Specific Discomforts Trimester Is this discomfort still Remedy/Midwife
Experienced being experienced measures taken by
(please encircle) (please encircle) patient
Breast Tenderness 1 2 3 YES NO
Palmar Erythema 1 2 3 YES NO
Constipation 1 2 3 YES NO
Nausea and 1 2 3 YES NO
Vomiting
Fatigue 1 2 3 YES NO
Headache 1 2 3 YES NO
Muscle Cramps 1 2 3 YES NO
Hypotension 1 2 3 YES NO
Varicosities 1 2 3 YES NO
Hemorrhoids 1 2 3 YES NO
Palpitations 1 2 3 YES NO
Urinary Frequency 1 2 3 YES NO
Abdominal 1 2 3 YES NO
Discomforts
Insomnia 1 2 3 YES NO
Nosebleed 1 2 3 YES NO
Backache 1 2 3 YES NO
Vaginal Bleeding 1 2 3 YES NO
Edema of feet, 1 2 3 YES NO
hands, ankles
Dyspnea 1 2 3 YES NO
Heartburn 1 2 3 YES NO
Pain when walking 1 2 3 YES NO
Burning feeling when 1 2 3 YES NO
urinating
Skin itching 1 2 3 YES NO

Code Guide for Maternal Discomforts responses:

Code Interventions of Patients
1 None
2 Self-medicated
3 Sought advise of family
members/relatives
4 Consulted traditional birth attendant/hilot
5 Consulted health center
6 Consulted physician in private practice
7 Consulted physician in government
practice
8 Others: please specify

Part 9: Current Medications

Name of Dosage and Route Classification
Medication Frequency

Part 10: Sleep/Rest Pattern

 Before Pregnancy During Pregnancy
Usual Sleep
Pattern/Bedtime
Factors affecting sleep

Part 11: Maternal Nutrition (indicate frequency of meals/foods likes and dislikes/usual
timing of meal)
Diet:
Pattern/Food/Fluid Intake:
Breakfast:
Lunch:
Snacks:
Dinner:,

Part 12: Elimination

Micturition Bowel Movement
Frequency
Usual Amount
Consistency
Usual Appearance

Is the patient taking diuretics? _

if Yes state reasons: _
Is the patient taking laxatives? _
if Yes state reasons: _

Part 13: Coping/Stress

Any stressful situations ever experienced during the course of present pregnancy?

Stress Management used/ Relaxation techniques employed:

Part 14: Prenatal Data

History of Prenatal Check up:
First Trimester:
Second Trimester:
Third Trimester: _

Tetanus Toxoid Immunization:

 Date Remarks
TT1
TT2
TT3
TT4
TT5

Prenatal Exercises practiced:

Fetal Heart Rate: Location: _______________
Fundal Height: Estimated Gestational Age:
Expected date of confinement (Naegele’s Rule):

Leopold’s Maneuver:
First Maneuver: _
Second Maneuver:
Third Maneuver:
Fourth Maneuver:

Maternal Blood Type: Maternal Rh:

Assessment of Uterine Contractions:
Usual Time of onset of Contractions:
Frequency:
Interval:
Duration:
Location of Contractile pain: Front: Sacral Area:
Degree of Discomfort: Mild Moderate Severe

Part 15: Laboratory Result

Laboratory Results Normal Values Interpretation Midwifery
Exam Intervention
HBsAg
Urinalysis

CBC

platelet count

Part 16: Medical Sociology Data

Access to Health Care Facilities and Services
Services availed at the Barangay Health Center (please check)
Immunizations
Vitamin Supplementation
 Health Education
Others:

Schedule of Visit

Frequency (encircle) Date Purpose

ONCE
TWICE
THRICE
FOURTH
More than 4x

Distance of Health center from home:

Environmental Sanitation
Type of Toilet (please check the column)
Level Description Indicators/Examples
Level 1 Type 1: Non-water carriage toilet -pit latrines
facility. No water needed to wash -reed odorless earth closet
waste into receiving space
Type 2: Toilet facilities requiring
small amount of water to wash
waste into receiving space

Level 2 On site toilet facilities of water -toilet with manual flush

carriage type with water sealed -toilet with flush button
and flush type with
septic tank/vault disposal
Level 3 Water carriage with septic tank -condominium type of toilet
connected to sewerage systems
to treatment plant

Garbage disposal (please check)

Burry/compost pit
Burn
Collected
Combination

Water source (please check)

Level Description
1 (point source) A protected well or
developed spring without
distribution system
2 (communal faucet A system with reservoir or
system/stand posts) piped distribution network
and communal faucet
3 (waterworks A system with reservoir,
system/individual home piped distributor network
connections) and household taps