SECTION A: MOTHER’S HEALTH RECORD

NAME : ________________________________________________________

I/C : ________________________________________________________

DOB : ________________________________________________________

AGE : ________________________________________________________

RACE : ________________________________________________________

CITIZENSHIP: ________________________________________________________

EDUCATION LEVEL: _________________________________________________

OCCUPATION : __________________________________________________

ADDRESS: __________________________________________________________

__________________________________________________________

__________________________________________________________

PHONE NUMBER : __________________________________________________

HUSBAND NAME : __________________________________________________

I/C : _________________________________________________

OCCUPATION : __________________________________________________

PHONE NUMBER : __________________________________________________

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 SECTION B: PREVIOUS PREGNANCY HISTORY

No. Year Pregnancy Type of Birth Gender Weight Complication Breastfeeding

Date of marriage: ____________________

SECTION C: MOTHER’S HEALTH DETAILS

Height
Period: Total days : ___________________ Cycle : ___________________
Blood Group : ___________________ Rh : ___________________
Result: VDRL/TPHA: ______________________________________________
: HIV (Rapid test): ___________________________________________
Family planning : Yes/No Method: ________________________
(If Yes) Period : ______________(Month/Year)

MOTHER’S HEALTH HISTORY

Diabetes Asthma Others: _______

Hypertension Heart problem

Allergy Tuberculosis

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MOTHER’S IMMUNIZATION

Rubella Date: _________________

Tetanus Dose 1 Date: _________________

Dose 2 Date: _________________

Booster Dose Date: _________________

FAMILY HEALTH HISTORY

Diabetes Asthma Others: _______

Hypertension Heart problem

Allergy Tuberculosis

MOTHER’S IMMUNIZATION STATUS :

Tetanus /toxoid 1st Dose :

2nd Dose :

Booster Dose :

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SECTION D: CURRENT PREGNANCY CONDITION

Height : Weight :

BMI :

CONSENT FOR BLOOD TAKING AND ANTENATAL SCREENING

Objective: -

To ensure mothers in an optimal health condition

To provide early intervention and treatment for current health problems

To prevent early infection to the baby

I ________________________________ I/C Number__________________________

Understood the verbal explanation and consent for my blood to be taken for the

following test: -

1. Blood group & Rh : _____

2. VDRL +/- TPHA : _____

3. Hemoglobin : _____

4. HIV (Rapid Test) : _____

5. Others : _____

The other sample will be taken whenever necessary

Signature Witness signature

____________ _______________

Date: Dr,

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BP MONITORING & SYMPTOM OF PRE-ECLAMPSIA

DATE BP HR ALBUMIN WEIGHT REMARKS

MGTT Result:

Date Fasting Blood Sugar 2H Postprandial

Glucose Monitoring

Date/ Time Pre-Breakfast Pre-Lunch Pre-Dinner Pre-Bed

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Notes:

…………………………………………………………………………………………………………………………………………

………………………..

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…………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………

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CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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Notes:

…………………………………………………………………………………………………………………………………………

………………………..

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…………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………

CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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Notes:

…………………………………………………………………………………………………………………………………………

………………………..

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…………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………

CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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Notes:

…………………………………………………………………………………………………………………………………………

………………………..

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…………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………

CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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Notes:

…………………………………………………………………………………………………………………………………………

………………………..

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…………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………

CURRENT PREGNANCY STATUS

Weight : BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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CURRENT PREGNANCY STATUS

Weight: BMI:

BP:

Date:

Urine Albumin : ____________

Urine Glucose : ____________

Hb : ____________

Weight : ____________

Blood pressure : ____________

Pulse : ____________

POG : ____________

Fetal Heart : ____________

Remarks : __________________________________________________

: __________________________________________________

: __________________________________________________

: __________________________________________________

: Next TCA ______________

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FETAL MOVEMENT CHART

Starting from _______, count the movement of fetal until reach 10 times. Please record
the time after completing 10 movements EVERY DAY.

ATTENTION!!
If you don't feel 10 movements within 12 hours, GO TO THE HOSPITAL
IMMEDIATELY.

Date/ Movement
Time
Time
1 2 3 4 5 6 7 8 9 10 Completed
9 am

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Date/ Movement Time
Time 1 2 3 4 5 6 7 8 9 10 Completed
9 am

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Date/ Movement Time
Time 1 2 3 4 5 6 7 8 9 10 Completed
9 am

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Date/ Movement Time
Time 1 2 3 4 5 6 7 8 9 10 Completed
9 am

ANTENATAL APPOINTMENT DATE:

Time Date Procedure Remarks

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