My O&g Clerking Template

FARAH HUSNA (040100848)
Prenatal Registration and Obstetrical Record Date
Name : Age : Bed :

RACE : Address :
 Malay  Indian  Chinese  Siamese  Other
Occupation : Gravid/para :
D.O.A : GESTATION : _____week______day
LMP? ________________________ Patient sure of her LMP?  Definite  Unsure
EDD ? _______________________
Please state the source of EDD taken :
CHIEF COMPLAINT :
HOPI
Name________________________________________
ANTENATAL History
Is this a plan pregnancy?  YES  NO Antenatal Problems :

Wanted pregnancy?  YES  NO  CHRONIC HPT  Insulin Dependent DM (IDDM)
 PIH  Non-Insulin Dependent (NIDDM)
How & When does pt suspect of this pregnancy?  PE  IGT
_____________________________________________________  Anemia  GDM
_____________________________________________________
How & When does pt confirm of the pregnancy? Treatment(if any) : __________________________________
_____________________________________________________ ___________________________________
____________________________________________________ ___________________________________
Booking date : ______________________

Booking place : _____________________
Booking : weight : ______ kg height : ______ cm
BP : _____________ Hb : _________
Total scan done : ________________ ANY RELEVANT DETAILS :

1st dating scan on :_______________ Place : __________________
Revealed correct EDD? :  YES  NO
Growth parameter ≈ date? :  YES  NO
Revealed any low lying placenta? :  YES  NO
Others : ___________________________________________
___________________________________________
dating scan on :_____________ Place : __________________

Revealed correct EDD? :  YES  NO
Growth parameter ≈ date? :  YES  NO
Revealed any low lying placenta? :  YES  NO
Others : ___________________________________________
___________________________________________
dating scan on :_____________ Place : __________________

Reveals : ___________________________________________
___________________________________________
Latest dating scan on :____________Place : _________________

Reveals : _______________________________________________
Fetal Movement: ______________________________________
2
Name________________________________________
PAST OBSTETRIC HISTORY
How many times have you been pregnant?
How many live births?
How many miscarriages or abortions?
How many children are at home?
Please list all past pregnancies.

NUMBE DATE WEEKS VAGINAL LENGTH ANESTHESIA / IOL / SEX OF WEIGHT COMPLICATIONS**
R PREGNANT OR OF VACUM / FORCEP BABY OF BABY
C-SECTION LABOR
1
2
3
4
5
PREV. PREGNANCY COMPLICATIONS :
 A STILLBORN BABY?
 A BIRTH DEFECT OR ABNORMALITY?
 INFANT DEATH FOLLOWING DELIVERY?
 A PREMATURE BABY?
 A BABY WITH A SERIOUS INFECTION?
 A BABY ADMITTED TO THE INTENSIVE CARE UNIT?
 A BABY WITH JAUNDICE
 EXCESSIVE BLEEDING (HEMORRHAGE) AFTER DELIVERY?
 HOSPITALIZATION BEFORE LABOR?
 ANY OTHER UNUSUAL OCCURRENCE?
3
Name________________________________________
PAST GYNAECOLOGY HISTORY
Age of Menarche : _________________

Was the period:  REGULAR or  IRREGULAR?
Every Days in Cycle ; each Lasting Days.
Regular menstruation flow for _________ days in ___________ days cycle.
Total pad soaked daily in heavy flow day : ______________
Pain or cramps with your period?  YES  NO  SOMETIMES.
Describe the last form of birth control you used before pregnancy : _________________________________
For how long duration ? ____________________( months / years )
When did you stop taking them? ________________________
Pap Smear done ___________ times. Latest was done on _______________.
Result? : _______________________________________________________.
YES NO CONDITION PLEASE EXPLAIN ANY “YES” ANSWERS.
GYNECOLOGY
  PROBLEMS WITH BIRTH CONTROL PILLS
  SEXUAL MOLESTATION, ABUSE, RAPE
  FIBROID TUMORS OF THE UTERUS
  OVARIAN CYSTS
  RECURRENT (FREQUENT) VAGINAL
INFECTIONS
  SEXUALLY-TRANSMITTED DISEASE (SYPHILIS,
GONORRHEA, CHLAMYDIA, HERPES,
TRICHOMONAS)
  PELVIC INFLAMMATORY DISEASE (PID)
  GENITAL WARTS
  MISCARRIAGE
  ABORTIONS (ELECTIVE)
PAST MEDICAL
HISTORY
Past SURGICAL history

YES NO CONDITION PLEASE EXPLAIN WHEN AND ANY OTHER IMPORTANT FACTS.
4
Name________________________________________
  LAPAROSCOPY
  D & C (DILATATION AND CURETTAGE)
  ANY OTHER SURGERY?
Past FAMILY history

YES NO CONDITION PLEASE NOTE WHICH FAMILY MEMBERS ARE AFFECTED.
  HEART DISEASE OR HEART ATTACK

  HIGH BLOOD PRESSURE
  TUBERCULOSIS
  DIABETES
  EMOTIONAL OR MENTAL DISORDER
  BLOOD VARIATIONS (THALASSEMIA, G6PD)
  BIRTH DEFECTS, DOWN SYNDROME, NEURAL
TUBE DEFECTS
  TWINS OR MULTIPLE BIRTHS
  PREGNANCY COMPLICATIONS
Social History
YES NO CONDITION
WHAT DO YOU DO ? : EDUCATION LEVEL :
 
DO YOU LIVE WITH YOUR HUSBAND?
 
DO YOU SMOKE?
 
DO YOUR HUSBAND SMOKE?
 
DO YOU DRINK ALCOHOLIC BEVERAGES?
 
ARE YOU FREQUENTLY EXPOSED TO:
LOUD NOISES?
CHEMICALS, SOLVENTS, OR PAINT
FUMES?
HIGH TEMPERATURES?
MERCURY, LEAD OR CADMIUM?
WHOLE BODY VIBRATIONS?
RADIATION?
PROLONGED STANDING?
DO YOU TAKE ANY

DRUGS?
List them.
ARE YOU ALLERGIC
TO ANY
MEDICATIONS?
List them.
ARE YOU ALLERGIC
TO ANY FOODS?
ON SUMMARY :
5
Name________________________________________
6
Name________________________________________
ASSESSMENT OF NUTRITIONAL STATUS

YES NO SOMETIMES STATEMENT
   I AM TAKING MY PRENATAL VITAMIN EVERY DAY.
   I SKIP MEALS OR REGULARLY GO LONG PERIODS WITHOUT EATING.
   I AM CURRENTLY CRAVING NON-FOOD ITEMS SUCH AS CLAY OR DIRT.
   I AM CURRENTLY FOLLOWING A SPECIAL DIET.
PLEASE PLACE A CHECK () BY THE FOODS YOU EAT REGULARLY
 LOW-FAT MILK  FISH  FRUIT  MARGARINE  WATER
 WHOLE MILK  CHICKEN/TURKEY  VEGETABLES  NUTS  JUICE
 YOGURT  LEAN RED MEAT  WHITE BREAD  COOKING OIL  SODA
(REG./FROZEN)  EGGS  WHEAT BREAD  CHOCOLATE  DESSERTS
 SOY FOOD  BEANS  BROWN RICE FAST/FRIED FOODS  COOKIES
 TEMPE  FRIED CHICKEN  WHITE RICE  GRAVY, SAUCES  PASTRIES
PSYCHOSOSIAL NEEDS ASSESSMENT

The purpose of this assessment is to determine if you may need the assistance of our social service staff.
AGREE DISAGREE UNCERTAIN STATEMENT
   I AM HAPPY ABOUT THIS PREGNANCY.

   MY LIVING CONDITIONS ARE SATISFACTORY.
   I AM FAMILIAR WITH THIS NEIGHBORHOOD AND THE MILITARY BASES IN THE AREA.
   MY MARRIAGE IS A HAPPY ONE.
   MY HUSBAND HAS NEVER ABUSED ME AND/OR THE CHILDREN.
   WHEN MY HUSBAND IS AWAY, I AM OK AND CAN MANAGE MY LIFE WELL.
   WHEN MY HUSBAND IS AWAY, I HAVE FRIENDS AND FAMILY TO HELP ME.
   WHEN MY HUSBAND IS AWAY AT WORK, I HAVE TRANSPORTATION TO MAKE MY APPOINTMENTS
AND GO SHOPPING.
   I DO NOT FIND LIFE STRESSFUL MOST OF THE TIME.
   I AM RARELY DEPRESSED.
   MOST OF THE TIME WE HAVE ENOUGH MONEY FOR FOOD AND EXPENSES.
   I DON’T DEPEND ON MY HUSBAND FOR EVERYTHING.
   MY HUSBAND WILL NOT BE DEPLOYED WHEN MY BABY IS DUE.
   MY CHILDHOOD WAS A HAPPY ONE.
   I HAVE NEVER BEEN PHYSICALLY OR EMOTIONALLY ABUSED IN MY LIFE.
   I SHOULD BE ABLE TO ATTEND MY PRENATAL APPOINTMENTS WITHOUT CHILDCARE CONFLICTS.
   WE DO NOT NEED FINANCIAL ASSISTANCE TO MAINTAIN OUR LIVES.
7
Name________________________________________
OVERALL :

My O&g Clerking Template

Uploaded by

Copyright:

Available Formats

My O&g Clerking Template

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

My O&g Clerking Template

Uploaded by

Copyright:

Available Formats

FARAH HUSNA (040100848)

Prenatal Registration and Obstetrical Record Date

Name : Age : Bed :

Is this a plan pregnancy?  YES  NO Antenatal Problems :

Booking date : ______________________

Total scan done : ________________ ANY RELEVANT DETAILS :

dating scan on :_____________ Place : __________________

dating scan on :_____________ Place : __________________

Latest dating scan on :____________Place : _________________

Fetal Movement: ______________________________________

PAST OBSTETRIC HISTORY

How many times have you been pregnant?

How many live births?

How many miscarriages or abortions?

How many children are at home?

Please list all past pregnancies.

PAST GYNAECOLOGY HISTORY

Age of Menarche : _________________

YES NO CONDITION PLEASE EXPLAIN ANY “YES” ANSWERS.

Past SURGICAL history

Past FAMILY history

  HEART DISEASE OR HEART ATTACK

WHAT DO YOU DO ? : EDUCATION LEVEL :

DO YOU TAKE ANY

ASSESSMENT OF NUTRITIONAL STATUS

PSYCHOSOSIAL NEEDS ASSESSMENT

   I AM HAPPY ABOUT THIS PREGNANCY.

You might also like

dating scan on :_ Place : ______

dating scan on :_ Place : ______

Latest dating scan on :Place : _____