Patient Profile
Clinical Instructor: _________________________ Area: ____________________ Date: __________
Surname: Age: Area:
First Name: Sex:
Past History:
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Present History:
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Clinical Instructor: _________________________ Area: ____________________ Date: __________
Surname: Age: Area:
First Name: Sex:
PHYSICAL ASSESSMENT
Diet Activities LOC Bladder Elimination O2 Therapy
Bath Mode of Affect Motor Status Bowel Elimination Safet Measures:
Clinical Instructor: _________________________ Area: ____________________ Date: __________
Surname: Age: Area:
First Name: Sex:
Others Others Others Others Others
Initial Diagnosis:
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Final Diagnosis:
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Clinical Instructor: _________________________ Area: ____________________ Date: __________
Surname: Age: Area:
First Name: Sex:
Clinical Instructor: _________________________ Area: ____________________ Date: __________
Surname: Age: Area:
First Name: Sex:
Vital Signs Monitoring
Vital Signs: BP RR PR Temp 02 Sat Input Output IVF
Date:
Clinical Instructor: _________________________ Area: ____________________ Date: __________
Surname: Age: Area:
First Name: Sex:
OB HISTORY:
Date of Initial Consultation: ___________________________ LMP: _______________________
GPTPAL: G_____ P_____ T______ P_____ A______ L______ EDD: _______________________
AOG in Weeks:_______________
Weight: ____________________
Obstetric Rick factors:
a. Multiple Pregnancy d. Placenta Previa g. Hx of pre-eclampsia
b. Ovarian Cyst e. Hx of miscarriages h. hx of eclampsia
c. Myoma Uteri f. hx of stillbirth i. Premature contraction
Others:
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Medical/Surgical Risk Factors:
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Clinical Instructor: _________________________ Area: ____________________ Date: __________
Clinical Instructor: _________________________ Area: ____________________ Date: __________
