Room no:

Patient ID No.:
Resident In-charge:

Dr.
Dr.
Intern In-charge:

Date of Birth:
Time of Birth:
Clerk In-charge:

Name:
Admitting Diagnosis: Live baby BOY/GIRL born FULL TERM/PRETERM/POSTTERM ,
LMP to a AGE OF MOTHER years old OB SCORE G P ( F - T - P CS# SECONDARY TO,

AS

, , BW

grams, A/S/L GA, BL

A-L

weeks &

days AOG by

) via NORMAL SPONTANEOUS DELIVERY/LTS

cm, HC

cm, CC

cm, AC

( ) meconium stain ( ) nuchal cord coil ( ) indication for CS

Birth Weight (gms):
Birth Length (cm):
Head Circumference (cm):
Chest Circumference (cm):
Abdominal Circumference (cm):

Apgar Score:
Ballard Score:
A/S/GA
HR
Temp
RR
O2 Sat

MBT
PBT
HbsAg
VDRL

OGTT
LMP

Antenatal History:
OB History:
Date:

Date:

Date:

cm.