Name : Date:

CHECKLIST FOR ANTENATAL ASSESSMENT

attempt

S.no. Content 1 2 3 4 5
1. Vaginal bleeding /leakage per vagina
2. Respiratory difficulty
3. Fever /foul smelling discharge
4. Severe headache /blurred vision
5. Generalized swelling of the body puffiness of face ,pitting pedal edema
6. Pain in the abdomen ,low urine output
7. Convulsion /lose of consciousness
8. Decrease excessive or absence of fetal movement
9. Perform immediate action in the event of any above the symptoms and
refer to the appropriate setting without any delay

INSTRUCTIONS :

Scoring is to be given as :

Performed well -2 perfromed average -1 did not performed -0

MAXIMUM SCORE : 09

SCORE OBTAINED :

REMARKS :

SIGNATURE OF STUDENT/FACULTY SIGNATURE OF SUPERVISOR