Name ---- Age------ socioeconomic status -------- residing at ---------- married for ---- occupation a-
----- G_P _ at ____wk ___day period of gestation, admitted on----------------- (date) with
Complaints of:
I) __________________________________ X ____________________
II) __________________________________ X ____________________
If patient does not offer any complaint, find out as to why she has been admitted. She may be admitted with
some high risk factor detected during routine antenatal check up at GOPD for evaluation and further
management (e.g. – Gestational hypertension, GDM, IUGR, Polyhydramnios etc).
So write that she was found to have ________________during routine ante natal check up, for which she has
been admitted for evaluation and further management
H/O present illness:
1. Elaborate the chief complaints over here (onset , progression, severity, radiation, aggravating and
relieving factors etc)
2. Comment on sleep , appetite, bowel and bladder habits
3. Finally comment on foetal movements
4. In case of no chief complaint write down the relevant negative history, e.g.—pain abdomen / leaking
P/V, bleeding P/V, fever, premonitory symptoms of severe gestational HTN etc
Menstrual History:
Age of menarche:
LMP –
EDD –
Earlier Cycle – ---------- (duration) / -------- (interval) days, regular
Obstetrics History: G__P__A___L__
1. In case of Primigravida - write Primigravida
2. In case of multi gravida , the previous obstetrics events are to be recorded chronologically, as follows
No Date of Antenatal Labour Method of Puerperium Baby
delivery period events delivery
1 2008 Spontaneous _ D&E
abortion at 9
wk
2 2009 Gestational Delayed Vacuum Uneventful Baby 3.8kg ,
hypertension second delivery cried at birth,
3rd trimester stage alive and
healthy
3 Present Pregnancy
H/O present pregnancy:
First Trimester
1. Planned conception / conceived after treatment of infertility/ did she start preconceptional FA
2. How was pregnancy diagnosed
3. When was her first antenatal visit
4. What was her weight at preconceptional period
5. Any hyper emesis/ threatened abortion/medical or surgical problem
6. Is she taking FA regularly
7. Comment on all basic ANC investigation (in case ante natal card has been given to you)
HB%
Urine RE/ME
HIV/ VDRL/ HBsAg
BS F/PP
USG – no of fetus, USMA, EDD as per USG, and whether it is matching with LMP or not.
Second Trimester:
1. Is she on regular antenatal check up
2. Is she taking Tab Iron / Calcium
3. Has she been immunised with Inj TT
4. Had she developed some complication e.g. bleeding P/V, urinary problem, anaemia, deranged sugar
level, any other medical or surgical problem
5. Weight gain in second trimester
6. Report of level II sonography
Third Trimester
1. Is she on regular antenatal check up
2. Weight gain
3. Any complication e.g. – APH, Gest HTN, UTI, anaemia, medical and surgical problem
4. Is the growth of fetus adequate
Past history:
Note down any current medical problem like – HTN, DM, Epilepsy, Bronchial Asthma, Bleeding Problems, drug
treatment and
Surgical Problem:
General surgical: appendicectomy, cholecystectomy, any other surgery
Gynae Surgical: D&C, myomectomy, fistula repair
Family History: h/o DM, HTN, TB, Blood dyscrasia, known hereditary disease, h/o of twining in family.
Personal History: Diet, contraceptive practice prior to pregnancy, smoking or alcohol habit, History of allergy,
H/O of prophylactic administration of anti-D
