GYNAE AND OBSTETRICS HISTORY
DERMOGRAPHICAL HISTORY
Name:________________________________________ Age:_________ Marital Status:________________
married since:______________ Occupation:____________________ Address:_____________________________
Gravida:_____ Parity:_________ LMP:_______________EDD:______________ Presented;____________________
PRESENTING COMPLAIN: Reason for her visit:
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HISTORY OF PRESENTING COMPLAIN:
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IF OSTERTICS:
1ST TRIMISTER:
When did you diagnosed about your pregnancy:____________
How did u diagnosed (urine test, BHCG Levels, Ultrasounds [9-11 weeks] )
Planned or unplanned?
Spontaneous or treated?
Lower abdominal pain, vertigo, vomiting (whether morning sickness or hyperemesis gravidarum),
bleeding, amenorrhoea, high grade fever with rash, vaginal discharge
Radiation exposure?
Fetal anomaly?
Medicine if taking recently?
2nd TRIMESTER:
Fetal movement
Antenatal booking
Medications (folic acid, iron or calcium supplements)
Bleeding, pregnancy induced hypertension, gestational diabetes, intrauterine growth retardation
Ultrasound for all investigations (20-22 weeks)
TETANUS HISTORY (1 1 6 1 1)
3rd TRIMESTER:
Medication
Bleeding
Discharge
Fetal movement
Ultrasound
PIH , GDM , IUD
MENSURAL HISTORY:
Age of menarche:___________ LMP:______________ Duration and regularity:_______________________
Amount and Flow:_______________________________________________________________________
Dysmenorrhea:_________________________________________________________________________________
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intermenstrual bleeding:______ Post-coital bleeding:__________ Vaginal discharge:
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Contraceptive pills:___________________
Menopausal symptoms [if the patient is suffering from
amenorrhea]:__________________________________________________________________________________
If postmenopausal [ age]:______
PAP SMEAR HISTORY:______________
Date of last pap smear: _____________________
Have you had abnormal pap smears?_______________
PAST OBSTERTIC HISTORY:
CHILD
Place of
Year delivery Duration Type of Complications Sex Birth Present health LACTATION
or of delivery mothers weight
abortion pregnancy and/or infant
PAST OBSTETRICAL/GYNECOLOGICAL:
UV prolapse Fibroid D&C hysterectomy tubal ligation vaginal or bladder surgery ovarian surgery
BIRTH CONTROL HISTORY:
What birth control method(s) do you currently use?
SEXUAL HISTORY:
dyspareunia:___________ How many times u meet with your husband:___________
Are there any concerns you want to share with your doctor?
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PAST MEDICAL HISTORY:
Arthritis:_______________ Diabetes:________ Diet controlled:___________ Insulin:__________________
High blood pressure:_____________ Heart disease:_____________ Kidney Disease:______________
Gallstones:_____________ Liver Disease :____________ Epilepsy:____________ Thyroid
disease:____________________ Blood Transfusions:__________________________________
Asthma:_____________ Emphysema:______________ Bronchitis:____________ HIV+:__________ Eating
Disorder:____________________________________________
PAST SURGICAL HISTORY:
Splenectomy Liver surgery pancreas surgery Tonsils thyroid laproscopy cholecystectomy
hernias:_______________________________________
DRUG HISTORY:
Medication Dose Frequency
Drug allergies: _________________________________________________________________________________
SYSTEMIC OVERVIEW:
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PERSONAL HISTORY:
Smoking:_____________ Alcohol:_____________ Exercise:_____________ Bowel habits:_____________
Sleeping habits:________________ . Use illicit drugs:___________ type ______________ amount
FAMILY HISTORY:
Diabetes:_________________________________ Hypertension:_______________________________________
Blood transfusion:______________________________ Miscarriages in family:___________________________
Twin pregnancy:_______________________________ Heart problems:_______________________________
How many people in your house and kids they are having:__________________________________________
SOCIAL HISTORY
No. of persons:__________ no. of rooms:_________ no. of earning peoples:________ earning monthly:_______
dependent on that earning:____________ surrounding hygiene:_____________ Water:______________ ________
facilities available:______________________________________________________________________________
SUMMARY:
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