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I) __________________________________ X ____________________
II) __________________________________ X ____________________
If patient does not have any chief complaints, mention negative history of Bleeding,
Leaking, Pain abdomen, Back ache, Foetal movements adequacy.
HOPI:
FIRST TRIMESTER
SECOND TRIMESTER
1. Is she on regular antenatal check up
2. Quickening (when)
3. Is she taking Tab Iron / Calcium
4. Level II sonography (Targeted anomaly scan)
5. Has she been immunised with TT
6. Weight gain in second trimester (if known)
7. Any other complications e.g.
Bleeding, UTI, anaemia (palpitations, fatigue), deranged sugar level, severe
headache, blurring of vision, decreased urine output, other medical or surgical
problems
THIRD TRIMESTER
Obstetrics History:
Menstrual History:
LMP –
POG –
EDD –
Age of menarche -
Cycle length -
Duration -
Amount of flow -
Passage of clots -
Past history:
Medical: HTN, DM, TB, Asthma, Epilepsy, STD, HIV/AIDS, Heart disease, Bleeding
Problems, Drug intake, Blood transfusion, any h/o hospitalisation
Surgical:
General surgical : appendectomy, cholecystectomy, any other surgery
Gynaecological : D&C, myomectomy, fistula repair
Treatment history:
Personal History:
Type of family, No. of family members, significant events last year, social relations,
stress in family, legal issues, taboos/stigmas
Any h/o DM, HTN, TB, blood dyscrasia, known hereditary disease, h/o of twining in
family.
Socio-economic history:
Total income :
SE status :
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DIAGNOSIS:
Ms _ _ _ is a _ _ _ yr. old primigravida/multigravida with _ _ _ weeks’ gestation (with
anaemia/HTN/past h/o of abortion).