HISTORY

IDENTIFYING DATA

Date of History:
Time of History:

Name, Age, Sex, Civil Status, Religion, Nationality, Occupation and Address
(Mrs. A.B, 28 year old, Female, Married, Catholic, Filipino is a Construction worker residing at Santo Domingo, Albay)

Informant: Reliability:
 Chief Complaint

The one or more symptoms or

concerns causing the patient to seek
care.
HISTORY OF PRESENT ILLNESS

• Amplifies the Chief Complaint

• Complete, clear, and chronologic

description (“OLD CARTS”) of the
problems prompting the patient’s
visit

• Pulls in relevant portions (pertinent

positives and negatives) of the ROS, helps
generate the differential diagnosis
HISTORY OF PRESENT PREGNANCY
“INITIAL PRENATAL HISTORY”
A. Confirmation of pregnancy and WHEN?
• Pregnancy test, LMP, USG
B. Signs and Symptoms of Pregnancy
• missed periods, breast tenderness, nausea or vomiting, fatigue, or urinary
frequency?
HISTORY OF PRESENT PREGNANCY
C. ANC Visits:
 Monthly until 28 gestational weeks, then biweekly until 36 weeks, then weekly until delivery.
 Nutrition :
 Take a diet history
 Review the body mass index (BMI)
 Recommend a prenatal multivitamin: (400 μg of folic acid, 600 International Units of vitamin D, 27 mg of iron,
and at least 1,000 mg of calcium, 150 to 290 μg of daily iodine in pregnant and breastfeeding women as
iodine deficiency is widespread.)
 Immunization:
- Tdap (ideally at 27 to 36 weeks of gestation)
- Inactivated influenza vaccination
 PAST MEDICAL HISTORY
MEDICAL SURGICAL
CONDITIONS HISTORY
HTN, DM, Cardiac Disorder, Abdominal or Pelvic
Blood Dyscrasias, Others Surgery

IMMUNIZATION/ HOSPITALIZATIO
CHILDHOOD N
DISEASES
 FAMILY HISTORY
Familial disease such Any history of
as DM, HPN, BA, hereditary illness or
RHD, CA congenital defects is
important

Previously affected
pregnancies with any
chromosomal or
genetic disorders
PERSONAL & SOCIAL HISTORY
PERSONAL HISTORY SOCIAL HISTORY
• Diet • Education
• Sleep Habits • Occupation
• Hx of Drugs or Alcohol abuse • Living status
• Bowel Habits • Total family members
• Exercise • Hx of travel
• Smoking • Source of income
• Any domestic violence
MENSTRUAL HISTORY

AGE AT
MENARCHE INTERVAL DURATION

AMOUNT OF
LMP REGULARITY FLOW
OBSTETRICS HISTORY
OB SCORE : G P (TPAL)
G: Gravida: Denotes a pregnant state both present and past, irrespective of the period of gestation.
P: Parity: Denotes a state of previous pregnancy beyond the period of viability.
T: Number of TERM PREGNANCIES(37-42 Wks)
P: Number of PRETERM PREGNANCIES (28 weeks to < 37 weeks)
A: Number of MISCARRIAGES (< 28 weeks)
L: Number of BABIES ALIVE at present
OBSTETRICS HISTORY
No. Date Term/ Mode of Gender Status at birth Complications
of Preterm/ Delivery and present
Preg Abortion
REVIEW OF SYSTEM
GENERAL: weight loss ,fatigue
SKIN: itching, rashes
HEENT: HEAD: headache, dizziness,
EYES: blurring of vision, pain, redness
EARS: tinnitus, vertigo
NOSE: itching, bleeding
MOUTH: sore throat, hoarseness,
RESPIRATORY: dyspnea, cough, hemoptysis
CARDIOVASCULAR: chest pain, orthopnea
GASTROINTESTINAL: epigastric pain, nausea / vomiting
REPRODUCTIVE : dyspareunia, menorrhagia ,amenorrhea, vaginal discharge, vulvar lesion
GENITOURINARY: genital lesion, dysuria, urinary frequency , hematuria ,pelvic pain
MUSCULOSKELETAL: joint pains
NEUROLOGIC: depression, mood changes
ENDOCRINE: excessive sweating, heat and cold intolerance
CALCULATE AOG & EDD
AOG EDD
LMP: JAN 3, 2021 Naegele’s Rule:
Today: May 17, 2021 LMP - 3 months + 7 days + 1 Year

Jan: 31 days – 3 = 28 days LMP : 7 /5/ 2016

Feb: 28 days -3 months/ +7 days / +1 year
Mar: 31 days EDD : 4 / 12/ 2017
April: 30 days
May: 17 days
Total: 134 days
134/7 days = 19 1/7 weeks [AOG]