FAIRFAX HOSPITAL

Prenala Record

Name Religion Date

Address Telephone

Occupation Business Business

Address Telephone

Husband’s Business Business

Name Address Telephone

Husband’s occupation Referred by

A Gravida Para Term Premature Abortions Living

ge

LMP PMP Quickening EDD

Significant History

Significant Findings

Date

Wt.(

B.P.

Edem

Hi.

Of
Fund

us

Positi

on

F.H + + + + + + + + + + + + +

Urine Sug

Pro

Gesta

tion

Move

ment

Initia

ls

RCT

Blood Rh STS Hgb Poa HBsAg

Group HCT

Rubella Glucala Alpha feto GC HIV

Protein

Ppd Chest Vitamin Berasi Bottle Anesthesia Pediatriciant

x-ray Supplement Preference

PROBLEM LIST
 Family planning information

Form

922

R91
FAIRFAX HOSPITAL

Prenatal Record Continuation

Name :

PRESENT PREGNANCY

Nausea : Vomiting : Other Symptoms

Of pregnancy

Bleeding : Cramping : Pain : Fdema :

Pregnancy Test Date

PREVIOUS PREGNANCIES

N Date Feed Wk Condition Durati Type Remarks

o Delifer - sex Wt s on of

ed ing Pre birt No Of Deliver

g h w labor y

6
PAST HISTORY

Menstruation Frequency Duration Flow Pain

Onset

Usual childhooa Rheumatic fever Heart disease Pulmonary

illnesses disease

Convulsions Venereai desiase Allergies Blood transfusion

Injuries Operations Urinary disease

Alcohoi Smoking Drugs Medication

FAMILY HITORY

Mother Father Siblings : Other

Diabetes : Twins :

PHYSICAL EXAMINATION

General : Ht : B.P Eyes : Fundi :

Ears : Mounth : Teeth : Throat : Thyroid :

Chesi : Breasts : Nipples : Heart : Lungs :

Abdomen Extremities :

Ext. genitalia : Perineum :

Vagina : Cervix :
Uterus :

Adnexa :

B.I.: D.C.: c.m. Arch :

c.m

Sacrum Spines :

Post.sagital : S.S ligaments : Coccyx

, M.D Forum

923 R87

SINGNATURE