Personal History :

The patient (mother) The husband

Name : Name :

Age : Age :

Occupation : Occupation :

Blood group : Blood group :

Marital Status : degree of kinship :

no. of children :
Religion : address :

Date of Admission : \ \ : A.M \ P.M

Date of Hx taking : \ \ : A.M \ P.M
Date of Examination : \ \ : A.M \ P.M
Date of operation or delivery : \ \ : A.M \ P.M

……………………………………………………………………………………
……………………………………………………………………………………
History of pregnancies :
LMP : \ \ make sure reliability of LMP :-
the first day of the last menstrual period regularity :
lactation :
contraception :

EDD : \ \ Pre – term : from 24 w to 36 w + 6 days

Term : from 37 w to 41 w + 6 d
expected date of delivery Post – term : more than 42 w
Post – date : from 40 w to 41 w + 6 d

Weeks of gestation : ( ) Weeks + ( ) days

G (No. of pregnancies regardless of the outcome):
P (No. of deliveries after 24 weeks gestation):
A (abortions before 24 weeks gestation): Ectopic pregnancy :
1st : Jan 2nd: Feb 3rd : March 4th : April 5th : May 6th : June
th
7 : July th
8 : Aug th
9 : Sep th
10 : Oct 11th : Nov 12th : Dec
 Chief Complaint :
……………………………………………………………………………
……………………………………………………………………………

History of presenting illness :

If the patient has pain
Site
Onset ? Duration ?
Severity ? Course ?
Character ? Radiation ?

Aggravating relieving factors

factors?
Associated
symptoms?

Vaginal bleeding : ‫أيضا تذكر انه تسال عن‬

Amount : - investigations
passage of clots - management
Colour :
Trauma :
Fever :
Fatigue :
Syncope :
Pain :
Fetal movement :
Vaginal discharge
Amount :
Colour :
Itching :
Odour :
Blood :
Fever :
Fetal movement :
Outcome :
Sexual intercourse:
 history of labor :
‫حسب قصة المريضة بترتيب زمني مالئم ومصطلحات طبية‬
Pre - delivery
Ask about show , regular painful contractions , fetal movement and vaginal discharge :

during delivery
Site of delivery : ‫بيت ام مستشفى ؟‬
Type of delivery : ‫قيصيرية ام طبيعي‬
Difficult or easy : ‫في حال كانت طبيعية‬
Duration of delivery : ‫وقت العملية او الوالدة‬
Type of Anesthesia: ‫في حالة كانت قيصيرية‬
Blood transfusion :
I.V fluid :
Any complications :

Post – delivery
Time of return of consciousness :
Analgesia :

Nausea, appetite, vomiting:

Fever :
Bowel motion, flatus :

post-partum hemorrhage :

Micturition after delivery :

Walking after delivery :
Breast milk amount :
 history of The outcome of delivery
Live or dead :
Admitted to neonatal
intensive care unit :
Male or female :
Weight of baby :
Crying after birth :
Infant movement :
Feeding :

Cyanosis :
Jaundice :
 Review of systems :
GIT
Anorexia :
Abdominal pain :
diarrhea :
constipation :
Flatulence :
Nausea & vomiting :
Weight loss :
Haematemesis :
Jaundice :
Dysphgia :
Melaena :
Bleeding per rectum :
CVS & Respiratory
Chest pain :
Dyspnea :
Claudication :
Orthopnea :
Palpitation :
Syncope :
Fatigue :
Ankle edema :
Cough :
Sputum :
Haemoptysis :
Wheeze :
Stridor :
GUT :
Dysuria :
Frequency :
Nacturia :
Urgency :
Urine retention :
Polyuria :
Haematuria :
Incontinence :
CNS: Endocrine :
 History of present pregnancy:
First trimester ( 0 – 13 ) weeks (ask about )
How pregnancy is
diagnosed
Planned or not
Nausea & vomiting
General health

Bowel motion
Vaginal bleeding
or discharge
Micturition

ANC
(ante natal care)

Drugs

Infertility

Others

Second trimester ( 14 – 28 ) weeks

fetal movement
Quickening
Bowel motion

Vaginal bleeding
or discharge
Vaccines

ANC
(ante natal care)
Micturition
Weight gain &
edema
drugs

…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
 Third trimester ( 29 – delivery )
Bowel motion

Fetal movement

ANC
(ante natal care)

Vaginal bleeding
or discharge
Weight gain &
Edema
Micturition
drugs

Past obstetric history :

Date of marriage : \ \ | Age of patient at marriage :
Date of first pregnancy : | Age of patient at first pregnancy :
Interval between current pregnancy and 1st pregnancy :
primary infertility :
secondary infertility :
Past pregnancies in sequence and ask the following questions for each child
year of pregnancy

Duration of pregnancy

Type of delivery

place of delivery

Gender of baby

Weight of baby

Congenital anomaly

cry immediate
Any problem to baby

Breast feeding
Puerperium
 Past gynaecological history :
Hx of Menstrual cycle

Age of menarche
Amount – pain – complications

Infertility
Sub-infertility

Pap smear

Contraception

Gynecological operation

Past medical history :

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………. D.M \ Hypertension
Asthma \ epilepsy
…………………………………………………………………………………. Heart problems
kidney problems
…………………………………………………………………………………. bleeding tendency
hyperlipidemia
………………………………………………………………………………….
Past surgical history :
Procedure Anesthesia Time Complications Outcome

Drug history :
Drug Dose Duration Indication Side effect

allergic history :
.
.
.
.
.

Family history :
.
.
.
.
.

Social history :
.
 typical story of history :
)‫…………………………… (االسم‬. is …… years old , (‫……… )عمل‬.. , her blood group is
……………… married from ………………………………. who is ……… years old ,
(‫…………… )عمل‬.. , his blood group is ……………. . there is (‫)درجة القرابة‬
…………………… . number of children are …….. . They lived at ………………………

- The patient is gravida …… para …… abortion ……. (G P A .)

- Her LMP was on: ………………. , So the EDD will be on ……………
- The date of admission ……………… , The date of taking history ………………So
the gestational age was ……………………
- The date of delivery ……………………….

The chief complaint was …………………………………………………………………..

………………………………………………………..
The patient presented with ……….
‫مفروض بعد هاي الجملة نكمل للنهاية نكتب كلشي سألنة المريضة عنة شغالت البوستف والنكتف نذكرها بشكل قصة‬
‫ويراعى فيها الترتيب الزمني لألحداث واستخدام مصطلحات حلوة وطبية وخفيفة بالوصف تنطي جمالية‬