Date:

ID
Name:
Age:
Residency:
Marital status and since when:
Occupation:
Source and reliability of it:
G_P_A_
Ges. Age:
Blood group for her and her husband & Last Hb
Chief complaint: What and for how long?
Hx of presenting illness: The client was doing well until she experienced ________________
1. Pain? SOCRATES
2. Gush of vaginal fluid? Was it the first time? Since when? How much? Color? Odor?
Consistency? Painful? Urine?
3. Vaginal bleeding? Was it the first time? Since when? How much? Color? Odor? Clots??
Painful? Number of pads used?
4. Vomiting? Was it the first time? Since when? How much? Color? Odor? Bloody? Mucous?
Painful? Projectile? Preceded by nausea?
5. Scheduled CS or D&C? Indications?
6. Uterine contractions? Since when? Frequency? Intensity? Regularity? Pain? Vaginal fluid or
bleeding? Cervical changes? Relieved by analgesics?
Hx of current pregnancy
G_P_A_
Ges. Age (by dates or by early u/s)
LMP:
EDD:
Spontaneous Vs planned pregnancy? (Induction & IVF)
Did she take folate and iron supplements?
Did she get pregnant while on contraception?
Singleton vs twins?
Was the route of pregnancy normal? /
Ask about any
tests her doctors
ordered

wheredisbokantemokes
↓

Did she use any drugs? a

Ask about all of her visits to her doctor(s).

· last antenatal
visit ? When ?
U/S and detailed u/s and why they were needed with the results. care

her Last BP ?
weight ?

Is she currently complaining of nausea? Vomiting? Swelling? Headache? Or fatigue?

Past obs Hx
she discharged
Betal,nee
+ when was

G_P_A_
Nuu
A

↑
# Gender Year Duration Weight Mode Place of Blood Complications Normal
of of delivery group or IVF?
pregnancy delivery
1
2
3
4
5

Past gynecological Hx
Menarche at age _____.
Is the period regular? (Cycle to cycle variation of less than 20 days is regular).
The period starts every ____ days. (normal is every 21-35 days) (less than 21 is polymenorrhea and
more than 35 is oligomenorrhea).
Duration of bleeding? (Normal is 4.5-8 days of bleeding) (More than 8 days is called menorrhagia).
 many pads
does
change day ?
she

Show
a

Is it light (<5ml)? Normal (5-80ml)? Heavy (>80ml)? (>80ml is also called menorrhagia).
Is the period preceded or accompanied by pain (dysmenorrhea)?
Is there any bleeding or spotting between periods? (Metrorrhagia).
Contraception methods ______ since______. (Pills/IUD)

Pap smear? Why? When? Results______.

Are there any signs of DVT? (Swelling? Pain? Warmth? Erythema? In the legs).
Past medical Hx
Disease When Drug(s)

Past surgical History

Surgery When Complication(s)

Drug Hx
Drug Dose For (disease) Duration

Family Hx
 Relationship Disease(s) Age diagnosed
Social Hx
Smoking? (Calculate packs per yr)
Alcohol?
House Ventilation: well ventilated vs poorly ventilated
Pets?
Pollution/Factories?
Recent travel?
Allergies to drugs/ food/ others? Since when? How is it managed?
Blood transfusions? Indication(s)?
Review of Systems
General
◻ Fever ◻ Undocumented
◻ Documented
◻ Chills ◻ Sweating ◻ Fatigue

Cardiovascular System
◻ Chest Pain:
Site:
Onset: ◻ Sudden ◻ Gradual
Character: ◻ Heaviness ◻ Stabbing ◻ Burning ◻ Other:
Radiation/Referral?
Time: ◻ Continuous Severity?
◻ Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
◻ Dyspnea: Onset: ◻ Sudden ◻ Gradual
Time: ◻ Continuous Severity:
◻ Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
◻ Orthopnea
◻ PND
◻ Dizziness/Syncope
◻ Palpitation
◻ Edema
◻ Claudication Distance:

Respiratory System
◻ Cough: Painful ◻ Yes ◻ No
Dry/Wet: ◻ Dry ◻ Wet
 Sound:
Time:
◻ Sputum: Amount:
Color:
Taste/Odor:
◻ Hemoptysis: Amount:
Appearance: ◻ Blood-streaked ◻ Clots
Frequency/Duration:
◻ Wheezing

Gastrointestinal System
◻ Mouth ulcers
◻ Dysphagia: ◻ Solids ◻ Liquid ◻ Both
◻ Intermittent ◻ Continuous
◻ Complete obstruction with regurgitation ◻ No regurgitation
Level food get stuck in:
◻ Odynophagia
◻ Nausea
◻ Vomiting: ◻ Preceded by nausea ◻ without warning
◻with abdominal pain ◻Without pain
◻ Pain relieved after vomiting ◻ not relieved
◻ Related to meals
◻ Related to times:
Amount:
Color:
Odor:
◻ Projectile ◻ Non-Projectile

◻ Hematemesis: Amount:
Appearance: ◻ Coffee-ground ◻ Fresh
◻ Preceded by retching
◻ Blood only appears after the first vomit
◻ Medications (NSAIDs/corticosteroids):
◻ Abdominal Pain: Site:
Onset: ◻ Sudden ◻ Gradual
Character: ◻ Colicky ◻ Constant ◻ Twisting ◻ Tearing
Radiation/Referral:
Time: ◻ Continuous Severity:
◻ Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
◻ Heartburn Relieved by:
◻ Weight loss (significant if >10% of weight in 6 months)
◻ Loss of appetite
◻ Altered bowel habit: Frequency ◻ Increased ◻ Decreased
Consistence ◻ Watery ◻ Soft ◻ Hard
Color:
Odor:
Blood: ◻ Melena (tarry-stool) ◻ Fresh
◻ Mucus
◻ Pus
◻ Tenesmus
◻ Urgency
◻ Incontinence

Urinary System
Color:
Odor:
Volume: ◻ Normal ◻ Increased ◻ Decreased
Frequency: ◻ Normal ◻ Increased ◻ Decreased
Stream: ◻ Normal ◻ Thick ◻ Thin
◻ Dysuria
◻ Hesitancy
◻ Urgency
◻ Incontinence
◻ Nocturia
◻ Hematuria

Nervous System
◻ Headache: Site:
Onset: ◻ Sudden ◻ Gradual
Character:
Radiation/Referral:
Time: ◻ Continuous Severity:
◻ Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
◻ Motor problems:
◻ Sensory problems:
◻ Change in personality/judgment:
◻ Convulsions
◻ Visual changes
◻Auditory changes
◻ Tinnitus
◻ Dizziness

Musculoskeletal System
◻ Muscle pain
◻ Joint pain
◻ Exacerbated by movement (mechanical)
◻ Relieved by movement (inflammatory)
◻ Morning stiffness (inflammatory)
◻ Limitation in movement
◻ Joint swelling
◻ Deformities

Skin
◻ Rash
◻ Pain
◻ Redness
◻ Swelling
◻ Itching
◻ Pigment changes
◻ Discharge/Bleeding
◻ Hair changes
◻ Nail changes
Endocrine pathologies?

Summary: (Name) is a (age) (job) from (residency) G_P_A_ at (gestational age), she was admitted at
(DOA) for (chief complaint), she has (important positives in hx).

Differential diagnosis: