MATERNAL HISTORY U P C N

HALCYO
2 0N1 9
I. Past History:

A. Maternal History
Gravida Para _____
Pre-natal check-up (for this pregnancy baby) Yes No
Where:
No. of Prenatal Visit: _________________
Illness during this pregnancy (specify): ______________________________________________________
X-ray exposure: At what month/trimester of pregnancy: ________________
Drug Intake: Yes No Nature of drug: _____________________________________________
Reason for taking the drug: ______________________________________________________________
When (trimester) Nature of drug: _____________________________________________

B. Birth History:
Full Term Premature Weight Length
Place of Birth: Hospital Home Others
Assisted by: Physician Nurse Nurse Midwife Others
Manner of delivery: Cesarean Forceps Vaginal
Indication
Presentation: Cephalic Breech Others

C. Maternal Complications (During Pregnancy of this child)

Hypertension Fever infection
Bleeding Others (specify)

D. Neonatal Complications
None Incubator care
Cyanosis Jaundice
Prematurity Difficult respiration
Others (ex. Congenital anomalies):
E. Past Illness (check if applicable)
o Cough
o Colds
o Diarrhea
o Fever
o Measles
o Parasitism
o Skin disease
o Others:
Hospitalization: No Yes
If yes, where:
For what :
When:
Duration:

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