RLE FORM 009

Cebu Normal University

College of Nursing
Cebu City

OB HISTORY

Name:___________________________ Date:___________ Taken By: ______________

I. Social and Personal Characteristics of the Patient:

Age:____ Marital Status:_________ Occupation:_____________ Religion:____________

Ethnicity:________________ Ht.:____ Wt:____ Number of Children in the Home:_____

II. Information Summary of the Spouse (Father of Baby):

Name:_________________________
Address:__________________________________
Age:______ Height:______ Weight:______ Ethnicity:____________________________

III. Characteristics Influencing the Course of Pregnancy:

LMP:__________ EDC:__________ AB Score:____________ Blood Type:ABO____Rh___

Pertinent Medical Conditions/Hospitalizations:___________________________________
Current Medications and Medication Habits: ____________________________________
Usual Bowel Patters:_______________________________________________________
Usual Sleep Patterns:______________________________________________________
Resume of Dietary Habits:__________________________________________________

IV. Attitudes Toward the Pregnancy:

Was the child planned?____________________________________________________

What are the patient’s goals and values regarding the pregnancy and other relevant
areas?
_______________________________________________________________________
Does she view this pregnancy positively or an interference in her life?
_______________________________________________________________________
What is her knowledge about health in general, pregnancy and childrearing in
particular?
_______________________________________________________________________
Does she have any previous experience with pregnancy and childrearing?
_______________________________________________________________________
What are her expectations and concerns about this pregnancy, birth and care of the
infant?
_______________________________________________________________________
What is her apparent willingness or disinclination to prepare herself in areas that need
attention?
_______________________________________________________________________

V. Resources

What appears to be her general level of intelligence of educations? ________________

_______________________________________________________________________
What is the level of economic stability? _______________________________________
_______________________________________________________________________
Is the family in tact? (cues) ________________________________________________
_______________________________________________________________________
Does she have sufficient friends from whom she can get tangible help and emotional
support if necessary?______________________________________________________

VI. Resume of antenatal classes and instruction:

Antenatal classes attended, individual and group instruction and counseling:
(Use back page for your answer)