OBSTETRIC FORM
Date of Examination: __________________________ Time:_________
I. BIOGRAPHIC DATA
Name:
Address:
Date of Birth: Age: Place of Birth: Blood Type:
Civil Status: Nationality: Religion:
Husband’s Name: Occupation:
Address:
II. OBSTETRICAL HISTORY
No. of children born alive: Illness during previous pregnancies:(please put a check
mark)
No. Of living children: ___None ____GDM ___PIH
No. of abortion ___Hyperemesis ____H-mole ___Asthma
No. Of stillbirths or fetal ___UTI ____Tuberculosis ___Hepatitis
deaths: ___Goiter ____Others:___________
History of large babies: (8lbs
& above):
Date of Last Delivery:
Type of Last Delivery: Previous Hospitalization
(Please Check)
____NSVD ____C-Section________ ____Forceps/Vacuum Extraction
(Indication)
III. PRESENT PREGNANCY
Menarche: Last Menstrual Period: Obstetric Score:
G_T_P_A_L_M_
Birth Rank: Expected Date of Delivery: Age of Gestation:
Fundal Height: PLAN OF DELIVERY
Plan to submit baby to Where to Deliver:_____________________
Newborn Screening: To be attended by:_____________________
___Yes ___No
IV. MEDICAL HISTORY
Allergies:__Tapes ___Iodine ___Latex ___No Known Allergies
____Drugs____________________________________________ Current
____Food_____________________________________________ Medication Taken:
____Environmental_____________________________________
____Blood Reaction ____________________________________
____Others___________________________________________
Childhood Illnesses:
Previous Hospitalization (Illness, accident, injury, surgery, blood transfusion):
Family Health History:
YES NO Member of the Family
*Heart Disease ____ _____ ________________________
*Hypertension ____ _____ ________________________
*Stroke ____ ______ ________________________
*Tuberculosis _____ _______ ________________________
*Diabetes Mellitus _____ _______ ________________________
*Cancer _____ _______ __________________________
*Kidney Disease _____ _______ __________________________
*Blood Disorder ______ ________ _________________________
*Asthma _____ _______ _________________________
Genogram:
V. Lifestyle
No Yes
*Alcohol Use _____ ______ Frequency:___________________
*Drug Use _____ _______ Type:________________________
*Tobacco Use _____ _______ No.of packs/day: ______________
*Use of Contraceptives _____ _______ Type:_____Length of Usage:_____
*Physical Environment: __________________________________________________
*Hobbies & Leisure activities______________________________________________
*Economic Status:______________________________________________________
PHYSICAL ASSESSMENT (ANTEPARTUM)
A. CARDINAL SIGNS
Blood Pressure: Temperature: Respiratory Rate:
Pulse rate: Height: Weight:
B. SKIN, HAIR, and NAILS
*Color
*Condition
*Lesions
*Moles
*Pigmentation
C. Nose
*Nasal Mucusa
D. Mouth
E. Neck
*Nodes
*Thyroid
F. Chest and Lungs
*Chest
*Ribs
*Breath Sounds
G. Breasts
*Color
*Vascularity
*Thickening and Enema
*Size and Symmetry
*Contour
*Lesions and Masses
H. Heart
I. Abdomen
*Striae
*Fundal Height
*Diastasis of rectus muscle
*Fetal Heart Beat
*Fetal Movement
*Ballotement
J. Extremities
K. Spine
L. Pelvic Area
*External Genitalia
*Vagina
*Cervix
*Uterus
*Ovaries
M. Laboratory Evaluation Patient’s Result
Blood Type
Complete Blood Count
Urinalysis
Capillary Blood Glucose
OGTT
HBSAg
Obstetrical Abdominal Palpation (Leopold’s Maneuver)
Maneuver 1
Maneuver 2
Maneuver 3
Maneuver 4
REMARKS:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
CRITERIA:
*Completeness (30) :_________________
*Conciseness (30):_________________
*Factual (30):_________________
*Promptness (5):__________________
*Neatness (5):__________________
Total (100):_________________
_______________ ________________
Name of Student Year and Section
_______________ _________________
Clinical Instructor Date of Examination
