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High Risk (Y/N):
High Risk Type:
FAMILY IDENTIFICATION
Mother ID Pregnant Woman's Age Husband/Father
P21010022881796
Name 20
Name
Sindhu NAVEEN KUMAR
District Mandal Village Caste
Mahabubnagar Mahabubnagar Urban Bandlageri (SC/ST/BC/OC/Minority)
BC-D
Mobile No. Husband/Father
7013662389
Mobile No.
EC Couple No. Aadhaar No. Bank Name Branch Name
EC271113 XXXXXXXX5846 STATE BANK OF INDIA GANESH NAGAR
Account No. IFSC Code
37183744527 SBIN0016375
PREGNANCY DETAILS
LMP Date EDD Date Blood Group RH Type
11-10-2022 15-07-2023 AB +ve
Last Delivery Name of the Facility Delivery Details
Conducted at
Govt
FACILITY DETAILS
Sub-centre Sub-centre ID ANM ANM Mobile No.
S.niranjanamma 9010244305
Asha ASHA Mobile No. AWW AWW Center No.
s sridevi 7989226965 Bandlageri II 1413084
AWW Mobile No. Ambulance Toll Free
Phone Number
102/108
BIRTH RECORD
Baby Gender Date of Birth Gender
Birth Weight
Regular Checkup Is Essential During Pregnancy By ANM
Regular Checkup Is Essential During Pregnancy by ANM
1st 2nd 3rd 4th 5th 6th 7th 8th 9th
Month Month Month Month Month Month Month Month Month
Month & Date
BP Have blood pressure (BP) checked at each visit.
HB %
Urine Have Urine examined at each visit.
Oedema Have Oedama examined at each visit.
Weight Have weight checkup at each visit. Gain at least 9-11 kg. during pregnancy.
Gain at least 1 kg every
month during the last 6 months of pregnancy.
T.D.Injection Take two T.D. Injections. T.D.1 when pregnancy is confirmed and T.D.2 after 1
month. (Fill in the date)
*Give one dose of T.D. if previously vaccinated within 3 years
Iron Tablets Take one tablet of iron folic acid a day for at least 6 months after first trimester.
Take at least 180
tablets. (Fill in quantity and date issued
Calcium Take two tablets of calcium per day for at least 6 months in 2nd & 3rd
Tablets trimesters
Albendazole Take single dose of tablet albendazole (400 mg) in 2nd trimester
Tablets
ANC 1
Date of Visit Result
ANC Date
Period of gestation (weeks)
weight in Kgs
Pulse rate
Blood Pressure
Anaemia (Y/N) N
Oedema (Y/N)
Jaundice (Y/N) N
Height of uterus (in weeks)
Foetal Heart rate (Per minute)
P/V if done
Any Symptoms
Management/Treatment
Date of Next Visit
Signature of MO/Gynaecologist
INVESTIGATIONS
Result Result
CBP VDRL
CUE HIV
Blood group type AB +ve HBsAg
RBS Thyroid profile
USG Report If done for Early Pregnancy NA
ANC 2
Date of Visit Result
ANC Date
Period of gestation (weeks)
weight in Kgs
Pulse rate
Blood Pressure
Anaemia (Y/N) N
Oedema (Y/N)
Jaundice (Y/N) N
Height of uterus (in weeks)
Lie/Presentation
Foetal movements
Foetal Heart rate (Per minute)
P/V if done
Any Sysmptoms
Management/Treatment
Date of Next Visit
Signature of MO/Gynaecologist
INVESTIGATIONS
Result
CBP
CUE
OGTT
RBS
USG Report1
TIFFA(If Done)
ANC 3
Designated Facility for 3rd ANC:
USG Scan(Y/N):
Date of Visit Result
ANC Date
Period of gestation (weeks)
weight in Kgs
Pulse rate
Blood Pressure
Anaemia (Y/N) N
Oedema (Y/N)
Jaundice (Y/N) N
Height of uterus (in weeks)
Lie/Presentation
Foetal movements
Foetal Heart rate (Per minute)
P/V if done
Any Sysmptoms
Management/Treatment
Date of Next Visit
Signature of MO/Gynaecologist
Other Investigations-(Y/N) :
INVESTIGATIONS
Result
CBP
CUE
OGTT
Blood Urea
Serum Creatinine
Space for USG Reports 2/3
ANC 4
Designated Facility for 4th ANC:
USG Scan(Y/N):
Revised EDD:
3rd ANC Done at Designated Facility(Yes/No):
Date of Visit Result
ANC Date
Period of gestation (weeks)
weight in Kgs
Pulse rate
Blood Pressure
Anaemia (Y/N) N
Oedema (Y/N)
Jaundice (Y/N) N
Height of uterus (in weeks)
Foetal Heart rate (Per minute)
P/V if done
Any Sysmptoms
Management/Treatment
Date of Next Visit
Signature of MO/Gynaecologist
Other Investigations-(Y/N) :
BIRTH PLANNING
Contact Details
Details EDD Date Facility
Name Mobile No.
Normal Pregnancy
High Risk Pregnancy
In case of emergency Free Transport (102/108)-
Delivery Details
Date of Delivery
Delivery Place
Delivery Outcome
Term/Preterm/Abortion
Complications, if any (Specify)
If at Institution, Period of Stay Post Delivery
Gender of Baby Weight of Baby
Cried immediately after birth
Injection Vitamin K
Name of the person who did delivery
Status
POST PARTUM CARE
3rd 7th 14th 21st 28th 42nd
1st Day
Day Day Day Day Day Day
Any complaints
Pallor
Pulse Rate
Blood Pressure
Temperature
Breasts (Soft/Engorged)
Nipples
(Cracked/Normal)
Uterus Tenderness
(Present/Absent)
Bleeding P/V
(Excessive/Normal)
Lochia (Healthy/Foul
Smelling)
Episiotomy/Tear
(Healthy/Infected)
Family Planning
Counselling (Y/N)
Any other Complications
and Referral
Requirements (Y/N)
If baby is less than 2 kg, contact ANM for support, for continued breastfeeding and Kangaroo
mother care
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