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Antenatal History Format

This document contains an antenatal history format that collects information from patients. It includes sections on patient profile, reason for hospitalization, menstrual history, obstetric history, family history, medical/surgical history, nutrition, partner's health history, psychosocial history, and findings from an antenatal examination. The examination assesses vital signs, appearance, skin, breasts, abdomen, fetal heart rate, extremities and performs pelvic assessments.

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Annapurna Dangeti
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9K views8 pages

Antenatal History Format

This document contains an antenatal history format that collects information from patients. It includes sections on patient profile, reason for hospitalization, menstrual history, obstetric history, family history, medical/surgical history, nutrition, partner's health history, psychosocial history, and findings from an antenatal examination. The examination assesses vital signs, appearance, skin, breasts, abdomen, fetal heart rate, extremities and performs pelvic assessments.

Uploaded by

Annapurna Dangeti
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ANTENATAL HISTORY FORMAT I. Patient profile Full name Age (in years) Hospital No. I. P. No.

Marital status separated Education status ccupation Hus!and"s name Age (in years) Education status ccupation #ype o$ $amily Per capita income %ate o$ !oo&ing %ate o$ admission: !stetric score 'ravida : : : : : : : : : : : : Married / unmarried/ divorced/ : : :

%ate o$ last antenatal visit

Para A!ortion M#P (iving II. Reason for hospitalization / Chief o!plaints

nset %uration )everity *elieving $actors Aggravating $actors III. Menstr"al histor# $

Age at menarc+e %uration o$ cycles *egularity Flo, - +eavy/moderate scanty - clots - no. o$ days Any dysmenorr+oea *elie$ measures (ast menstrual period Period menstrual period I.. O%stetri histor#$ Present O%stetri histor# Is pregnancy con$irmed : /es / No

0+en1 ,+ere and +o, it ,as con$irmed 0+at test ,as done $or con$irmation 2uic&ening Immuni3ation Any more disorders li&e : .omiting1 +aemorr+oids1 +eart !urn1 !ac&ac+e1 !leeding1 varicose vein1 constipation1 leg cramps1 $ever1 leucorr+oea1 anore4ia1 insomnia1 ot+er complaints. Past O%stetri Histor#

)l No

%ate o$ delivery Place o$ !irt+ %uration o$ pregnancy

Met+od o$ delivery 5ourse o$ pregnancy

(a!or

.. Fa!il# Histor#$ 5ongenital diseases

Any +ereditary diseases Multiple pregnancy %ia!etes Heart disease Any mental retardation Hypertension or PIH (in mot+er/ sisters) #,in pregnancy I$ yes1 In ,+om 6 Mot+er / Fat+er 6 .I. Me&i al'S"r(i al Histor#$ 5+ild +ood disease 5+ronic disease li&e ast+ma1 dia!etes1 epilepsy Previous surgery In7uries especially o$ !ac& and pelvis Hepatitis1 )#%1 HI. History o$ anemia Any medication ta&en at present or past *eason $or use1 date stopped 8lood trans$usion1 allergic reaction .II. N"trition$ 'eneral nutrition 9 veg / non-veg Appetite 9 decreased/increased Any eating disorders :; +ours recall .III. Partner)s Health Histor#$ 'enetic a!normalities 5+ronic diseases In$ections <se o$ drugs suc+ as cocaine alco+ol

)mo&ing +a!its : to!acco1 cigarette )e4ually transmitted diseases 9 HI./ AI%) 8lood type I=. Ps# ho'so ial histor#$ Emotional c+anges e4perienced 0omen"s and $amily"s reactions to present pregnancy Family support system 9 Family mem!ers and $riends 5oping strategies (i$e style c+ange )ocial relations+ips ,it+ t+e neig+!ours Financial support ANTENATAL E*AMINATION 'eneral Appearance: Nouris+ment 8ody !uilt Heig+t 0eig+t .ital signs : : : : : #emp : Pulse : *espiration : 8.P.

Mental stat"s $ Hea& to foot e+a!ination $ )&in turgor:

Moisture : 0armt+ / #emp : Fa e$ Facial pu$$iness: (ips: Eyes: Peri-or!ital oedema: 5on7unctive : Pallor Mout+: #ongue: Chest$ #+ora4 : : 8reat+ sounds : : : Heart : A4illa 8reast : crust : )+ape )ymmetry o$ e4pansion posture : .esicular sounds 0+ee3ing / *+onc+i 5repitations Pleural ru! : +eart rate (ocation o$ ape4 !eat/ 5ardiac murmurs : any lymp+ node enlargement : any tenderness / pain$ul tense / dilated veins / ,armt+ / presence o$ Moisture 5yanosis1 dryness

Nipples A%&o!en

retracted / inverted / crac&ed

Inspection : present/not

)i3e1 s+ape1 contour1 $lan&s1 um!ilicus1 $oetal c+anges1 5ontractions

movements1 s&in Palpation:

- Fundal palpation: In$erence : (ie Presentation - (ateral Palpation: (e$t side 9 description *ig+t side 9 description In$erence : Position Pelvic palpation : In$erence : Presentation Engagement / not engaged Attitude - Pa,lic& 'rip: Fi4ed/ Mo!ile - First pelvic grip : %escription

Auscultation :

- FH* - r+yt+m - location

E+tri!ities : An&le oedema : 5apillary re$ill : 5yanosis :

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