Socio-Demographic details:

Patient_____________ (Name),______ years (Age) old ________ (Marital status) , Gravida______ Para_________Abortion____________Live Birth __________ Still birth_______ with_______ of gestation (gestation in weeks) educated up to _______  (Education) working as a ____________(Occupation) of ______ (Religion) belonging to socio-economic class ___ (Socio-economic class) was admitted in the hospital on________  (Date of Admission) 

Chielf  Complaints: 

Details of the chief complaints with which the patient presented - origin, duration, progress (ODP) and associated events

1)

2)

3)

Present History: 

• Details of the chief complaints with which the patient presented - origin, duration, progress (ODP) and associated events

• Symptoms suggestive of complications (Pain in abdomen, palpitations, easy fatigability and breathlessness at rest, swelling all over the body and puffiness of face, severe headache, blurring of vision, convulsion, bleeding per vagina, watery discharge per vagina, fever >38.5oC/for more than 24 hours, persistent vomiting, reduced or absent foetal movements, preterm labour etc.)

• Any treatment taken for the current symptoms. Mention all the relevant details.

• Details of any current systemic illness and its treatment ( e.g. hypertension, diabetes, heart disease (Breathlessness on exertion, palpitations), Tuberculosis, Leprosy renal disease, epilepsy, asthma, jaundice, malaria, reproductive tract infections,  sexually transmitted infections, HIV-AIDS). These are the risk factors of pregnancy.

• Any history of exposure to radiation to current pregnancy.

• ANC Care ( ANC registration done in which trimester, Total no. of ANC visits till date/ frequency of visits, Intake of iron folic acid tablets, and  calcium tablets, Immunisations taken - number of Td doses received and the trimester in which it was received

Menstrual History: 

Age of menarche

Date of last menstrual period -

Calculate Expected Date of Delivery

Past Menstrual Cycle: Duration ______________, Regularity _______________________, Pain during menses __________________ , 

Flow - less/moderate/heavy

Family Planning: 

Family planning method used and duration of its use.(planned or unplanned pregnancy)

Immunization History: 

• Tetanus vaccine - Td (number of doses received and the trimester in which it was received)

• Covid-19 vaccine - Name of vaccine received, Number of doses received and date of last dose taken.

Past Obstetric History: 

Gravida _____ Para _______Abortion _______Live birth _________ Stillbirth ________ . (Mention here if  any child born as live birth died subsequently and the cause of death. If there is history of recurrent early abortions, record the details and mention if any post-abortion complications occurred)

Ask for each pregnancy - the birth history and complications and inj tetanus toxoid. State the present age and sex of child.

Details of the previous birth history (Term, place and 

nature of delivery, complications during delivery, delivery

conducted by, birth weight of baby, did baby cry

immediately after birth. breast feeding started when,

history of any prelacteal feeds, difficulties in breastfeeding

and duration of breastfeeding)

History of complications or significant events in the 

past pregnancies (Complications or significant events 

could include hypertension, pre-eclampsia or eclampsia, 

Ante-Partum Haemorrhage (APH) a caesarean section / a 

instrumental delivery / breech delivery / manual removal of 

the placenta, perineal injuries/tears, excessive bleeding 

after delivery, puerperal sepsis, blood transfusions)

Past History:  (If yes mention details)

History of TB, hospitalisation or any major surgery in the past.

Surgery on the reproductive tract is a risk factor.

Personal History: (If yes mention details)

Tobacco and alcohol consumption, Allergies, Adverse drug reactions, sexual exposure, bladder/ bowel complaints, sleep, appetite, physical exercise

Family History: 

History of Twins in family / congenital malformations

History of Hypertension or Diabetes in the family

Any family member suffering or had TB

Any current major chronic illness in family

History of thalassaemia or whether anybody in the family has received repeated blood transfusions. 

Socioeconomic History: 

Details regarding the following should be obtained in history.

• No of person/s living in family and age and sex of family members and their relationship.

• No. of earning family members and total income.

• Find out who is the head of the family and their details of educational and occupation.

Calculate socio-economic class using BG Prasad Classification or Modified Kuppuswamy Classification.

Environmental history:

• Lives in Urban slum / Urban Non slum/  Rural

• Housing: Type of house i.e. kaccha / pukka /semi pukka, area of house, etc.

Social Cultural Practices:

Values/ Customs / Habits / Beliefs / Attitudes / Religion / Lifestyle / Education / Occupation / Stress (Home/ Workplace) / Health services in community. Identify the good and harmful practices.

Dietary History: 

Take dietary assessment using a 24 hour recall method. Analyse her diet to check caloric , protein, iron and calcium intake and summarise as follows.

________(Patient name) consumes _______________(vegetarian /non-vegetarian food) food and eats ____ meals per day (no. of meals). Her total caloric intake is _____ kcals and _____ gms of proteins is being consumed.

Her diet is deficit /excess by ____ kcals and _____gms of proteins.

Her diets also lacks/ has limited / adequate  intake of iron and calcium rich food 

General examination:

Built_____________________  Weight in  ___________kg and height of ____________ cms.

Pulse rate is  ____________ per min.

BP is ______ mm of Hg in supine position measured in the left arm. 

Respiratory Rate is __________ per min.

Pallor / No signs  of pallor, icterus, cyanosis, clubbing or lymphadenopathy.

Pedal oedema is present / absent.

Breast examination is normal / revealed inverted nipple.

Obstetric Examination:

• Inspection: 

• Palpation: 

Fundal height..........weeks 

Symphysio-fundal height:........cms.

Abdominal girth:......cms 

Fundal grip

Lateral grip

First pelvic grip

Second pelvic group

• Auscultation : Foetal Heart Sounds

Systemic Examination:

Cardiovascular system:

Respiratory system:

Central Nervous system

Case Summary: 

Provisional Diagnosis: