Britney Aguilera, a 28 years old patient residing at #143 Brgy.

Maswerte Pasig City visits the health center today for her first
prenatal check-up. Her height is 150 cm, weighing 60 kg and has
type (+)A blood. LMP: November 28, 2012.
The patient has no current health problems.
Obstetrical history:
G1 = 2007, died @20 wks due to infection.
G2 = 2008, NSD, 38 weeks, Alive bb Boy, Fabella Hospital, (-) pp complication
G3 = 2010, NSD, 40 weeks,Alive bb Girl, Fabella Hospital, (-) pp complication
G4 = Present pregnancy

Upon Assessment:

Cephalic

Negative pallor

FHT: 150 bpm (RLQ)

Negative edema

BP: 120/80 mmHg

No history of spotting

Negative vaginal infection

Afebrile

FH: 20 cm

TT3 (administered last January 25, 2012)

Afebrile

With dental Check-up last December 2012.

Name: ____________________________________
Age: ______________________________________

LABORATORY REQUEST FORM

Name: ____________________________________
Age: ______________________________________

LABORATORY REQUEST FORM

Name: ____________________________________

Name: ____________________________________

Age: ______________________________________
Requested by: ________________

Age: ______________________________________
Requested by: ________________

LABORATORY REQUEST FORM

LABORATORY REQUEST FORM

Name: ____________________________________
Requested by: ________________
Age: ______________________________________

LABORATORY REQUEST FORM

Britney Aguilera, a 28 years old patient residing at #143

Brgy. Maswerte Pasig City visits the health center today for
her first prenatal check-up for her 3rd pregnancy. Her

Requested by: ________________

height is 150 cm, weighing 60 kg and has type A blood.

LMP: July 7, 2011. The patient has no current health problems.

Obstetrical history:
G1 = 2008, NSD, 38 weeks, Fabella Hospital, (-) pp complication
G2 = 2010, NSD, 40 weeks, Fabella Hospital, (-) pp complication
G3 = Present pregnancy
Upon Assessment:

Cephalic

Negative pallor

FHT: 150 bpm (RLQ)

Negative edema

BP: 120/80 mmHg

No history of spotting

Negative vaginal infection

Afebrile