3. III. DELIVERY DETAILS:
Type of delivery-
Date of delivery-
Time of delivery-
Blood loss-
Medications, if given-
Episiotomy-
Placenta-
IV.OBSTETRICAL HISTORY:
PASTOBSTETRICAL HISTORY:
PRESENT OBSTETRICAL HISTORY:
V. PAST HISTORY OF ILLNESS:
PASTMEDICAL HISTORY:
PASTSURGICAL HISTORY:
4. VI. FAMILY HISTORY:
VII. MENUSTRAL HISTORY:
VIII. MARITAL HISTORY:
IX. CONTRACEPTIVEHISTORY:
X. SEXUAL HISTORY:
XI.PERSONAL HISTORY:
Nutrition-diet:
Rest & Sleep:
Elimination pattern- Bowel:
Bladder:
5. Hygiene:
Habits:
XII.ANTENATAL HISTORY:
I TRIMESTER:
II TRIMESTER:
IIITRIMESTER:
NUMBER OF ANTENATAL VISITS:
IMMUNIZATION:
IRON& FOLICACID SUPPLEMENTATION:
XIII. SOCIO-ECONOMIC HISTORY:
XIV. ENVIRONMENTAL HISTORY:
XV. PHYSICAL EXAMINATION:
GENERAL APPEARANCE:
Body built:
Nourishment:
Mental status:
Height:
Weight:
9. NEW- BORN ASSESSMENT:
Name of the baby-
Mother’s name-
Sex of baby-
Date of delivery-
Time of delivery-
Type of delivery-
Apgar score-
Weight of the baby-
Anthropometric measurements-
Length of baby:
Head circumference:
Chest circumference:
Abdominal circumference:
Reflexes-