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OBSTETRICS AND GYNAECOLOGY

HISTORY TAKING
1. Introduction
Name:
Age:
Gravida:
Para:
Job:
Ethnic group:
POA:
Previous Obstetric History:
Why reffered/admitted:
Acute symptom(s):

1.
2.
3.
4.
5.
6.
7.
8.
9.

Introduction
Menstrual History
History of Present
Pregnancy
Past Obstetric
History
Past Gynae History
Past Medical &
Surgical History
Family History
Social History
Summary

E.g. Puan Siti Mariam is a 32 year old Malay school teacher , Gravida
3.Para 1, Abortion 1, at 38 weeks gestation, admitted for an Elective
Caesarean Section for a Breech Presentation.
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2. Menstrual History
Age of Menarche:
Age of Menopause(if appropriate):
Period:
Regular/Irregular
Frequency(How often do your periods come?)
Duration(How long do they last?)
No of pads/tampons used per day
Flooding
Passage of clots
Dysmenorrhoea:
Menorrhagia:
Bleeding(Intermenstrual, Postcoital, Postmenopausal):
First Day Of the Last Normal Menstrual period(LNMP):
Expected Date Of Delivery(EDD):

Corrected/Revised EDD:
3. History of Present Pregnancy
Planned/Unplanned:
When Confirmed? How? Where? UPT or U/S?
Problems in First Trimester(Bleeding, vomiting):
Booking(1st antenatal visit)
o Where?
o Rountine Investigations: Wt:______ Ht:_____ BP:______
Quickening(1st fetal movement):
MGTT(done in 2nd trimester):
Antenatal checkup
o How often?
o Number?
Colour coding(white, green, yellow, red):
Blood tests
o Hb:
o Blood Group:
o Rh:
o Infective Screening(HIV/VDRL/Hepatitis):
Urine examination(for albumin & sugar):
Problems in 2nd trimester(e.g.: anaemia):
Problems in 3rd trimester(Medical/Obstetric):
4. Past Obstetric History
Gravida:
Para:
Abortions/ectopics/molar:
Each pregnancy:
o Date:
o POA:
o Type of Delivery:
o Where:
Baby Details:
o Wt:
o Sex:
o Condition at birth(Did baby cry immediately after birth?)
Complications in 1st, 2nd, 3rd trimesters:

Any procedures done?(ICU/LR/HDW etc):


Breastfeeding:
Immunisations:
Contraception:.
Abortions.TypeD&C..Confirmed or not.HPE:
Ectopics/Molar.Details:

5. Past Gynaecological History


Any previous gynae history?
o e.g. fibroids, endometriosis, PID
Any operations done? (Details/complications):
Pap smear(How often? Results):
6. Past Medical and Surgical History
Any medical history?
o Disease:
o Admissions:
o Treatment given:
Any chronic illness?(e.g. diabetes, hypertension)
o Long term treatment:
Any surgical operations? Details:
MVA any problems? What injuries she had? (pelvis injury?):
Diseases which effect pregnancy:
Pregnancy worsens the diseaseeg Heart diseases:
7. Family History
Parents, details:
Chronic diseases in family:
Siblings:
o Number of siblings:
o Girls..diseases (eg fibroids):
Multiple pregnancy:
Fetal abnormalities:
Malignancy:
8. Social History
Patients workdetails..monthly income:
Husbands work..details..monthly income:
Total family monthly income:

Husbands medical history..if any:


Smoking:
Alcohol:
Illicit Drugs:
Accommodation details(Elecrtricity/Water/Sanitation):
Diet History

9. Summary
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