Scribd
Upload
74 views

Prenatal Check Up Interview

The document provides forms and instructions for conducting a maternal health assessment. It includes sections for collecting a patient's personal and medical history, obstetric history, risk factors, antenatal history, family health history, past medical and surgical history, and a review of systems. The assessment gathers information on demographics, pregnancies, current signs and symptoms, diagnostic tests, immunizations, medications, family illnesses, hospitalizations, surgeries, and findings from inspection, percussion, palpation and auscultation of various body systems.

Uploaded by

SHIELOU LOMOD
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
74 views

Prenatal Check Up Interview

The document provides forms and instructions for conducting a maternal health assessment. It includes sections for collecting a patient's personal and medical history, obstetric history, risk factors, antenatal history, family health history, past medical and surgical history, and a review of systems. The assessment gathers information on demographics, pregnancies, current signs and symptoms, diagnostic tests, immunizations, medications, family illnesses, hospitalizations, surgeries, and findings from inspection, percussion, palpation and auscultation of various body systems.

Uploaded by

SHIELOU LOMOD
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 7

MATERNAL HEALTH ASSESSMENT

Instructions: Kindly fill out the forms with the necessary information of the patient. Write legibly and
accurately.

I. PATIENT’S PROFILE
Name : __________________________________ Age: _______________
Birth Date : __________________________________ Sex: _______________
Religion : __________________________________ Civil Status: _________
Address : __________________________________ Height: _____________
Educational Attainment : __________________________________ Weight: _____________
Occupation : __________________________________ Blood Type: _________
Ethnic Group : __________________________________ Vital Signs
Date & Time of Admission : __________________________________ PR/HR : _____
Attending Physician : __________________________________ RR : _____
Chief Complaint/s : __________________________________ BP : _____
Medical Diagnosis : __________________________________ Temp : _____
__________________________________
__________________________________
History of Allergy/ies: __________________________________
__________________________________
__________________________________

II. OBSTETRIC HISTORY


LMP: _____________________ G: ___ P: ___ (T: ___, P: ___, A: ___, L: ___)
EDC: _____________________
AOG: _____________________
Menarche Age : __________________ Menstrual Cycle : _________ days
Duration : __________________

MANNER
GRAVIDA PLACE OF DELIVERY AOG OF PRESENTATION COMPLICATIONS
DELIVERY
G1
G2
G3
G4
G5
G6
G7
G8

III. OBSTETRIC RISK FACTORS


( ) Age (below 18 and above 35) ( ) Multiple pregnancy ( ) Ovarian Cyst
( ) Uterine Myoma ( ) Placenta previa ( ) History of still birth
( ) History of 3 Miscarriages ( ) History of pre-eclampsia/eclampsia
( ) Others: (please specify) __________________________________________________
__________________________________________________
__________________________________________________
IV. ANTENATAL HISTORY
1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

Number of
Visits

Signs &
Symptoms of
Pregnancy

Diagnostic/s &
Laboratory
Test/s Result

Immunization/s
Given

Medication/s
Taken

V. FAMILY HEALTH HISTORY

( ) Diabetes ( ) Bleeding disorder ( ) Mental Disorder ( ) Heart disease ( ) HPN


( ) Asthma ( ) Allergy ( ) Epilepsy
( ) Others: ___________________

VI. PAST HEALTH HISTORY

Past Medical History:


Hospitalized? ( ) Yes ( ) No When?____________________
If yes, cause of hospitalization:
_________________________________________________________________
_________________________________________________________________
_______________________________________________
Past Surgical History: ( ) Yes ( ) No When?____________________
If yes, type of surgery:
___________________________________________________________
___________________________________________________________
___________________________________________________________

VII. FAMILY PLANNING METHOD HISTORY


A. Natural Method
( ) Calendar Method ( ) Abstinence ( ) Withdrawal
( ) Cervical Mucus ( ) Basal Body Temperature ( ) Standard Days Method
( ) Lactational Amenorrhea Method ( ) Others: ______________________________

B. Artificial Method
( ) IUD ( ) Pills ( ) Injectable (DEPO) ( ) Bilateral Tubal Ligation (BTL)
( ) Condom ( ) Intradermal Implant ( ) Others: ______________________________

REVIEW OF SYSTEMS

Instructions: Kindly accomplish this matrix. Be sure to fill out with normal and abnormal findings. Follow the
IPPA or IAPP (Inspection, Percussion, Palpation and Auscultation) format. (Only for systems that are
applicable)
BODY PART/SYSTEM FINDINGS NURSING DIAGNOSIS

GENERAL SURVEY/
MENTAL STATUS

Integumentary
BODY PART/SYSTEM FINDINGS NURSING DIAGNOSIS

Head & Face

Neck

Eyes

Ears
BODY PART/SYSTEM FINDINGS NURSING DIAGNOSIS

Nose & Sinuses

Mouth & throat

Lungs & Thorax

Breast & Axillae


BODY PART/SYSTEM FINDINGS NURSING DIAGNOSIS
Heart

Abdomen

Gastrointestinal/Nutrition

Musculoskeletal

Genitourinary

Neurologic

You might also like