Name of Patient: Hospital:

Informant: Department: Obstetrics and Gynecology

Reliability: Preceptor:
Historian: Date taken:
Section and Group: Date submitted:

OBSTETRICS HISTORY
GENERAL DATA
Patient's initial: __________ Age: ________ G_P_ (_ _ _ _) Civil status: _______
Nationality: _____________ Religion: ________ Place of birth: ___________________
Current residence: ____________________________________
Nth consultation: __________ Date and time of consultation: ____________

CHIEF COMPLAINT: _________________-

PAST MEDICAL/SURGICAL HISTORY

Do not include previous hospitalization due to deliveries (VSD, CS, ectopic pregnancy, etc) which should be included
instead in the OB history
A. Allergies B. Cardiac Disease
C. Diabetes D. Epilepsy
E. Exposure to Rubella F. Gonorrhea
G. Hepatitis H. Hypertension
I. Immunization J. Renal Disease
K. Thyroid Disorder L. Tuberculosis
M. BLOOD TYPE: ____Patient _____Husband

Surgical History
A. Diagnosis
B. Date of operation and type of operation
C. Surgeon and hospital where performed
D. Histopathological result
E. Outcome
Gynecologic History:
a. Surgery, Diagnosis, Hospital, Physician, Biopsy, Outcome, Date
b. Sexually Transmitted Infection

FAMILY HISTORY
Positives and pertinent negatives, always try to elicit the following: (indicate relationship/consangunity to patient)
Heredofamilial illness: _____hypertension _____diabetes mellitus _____cancer ____asthma ____heart disease
Communicable diseases: _____PTB _____ Hepatitis
_____ History of multifetal pregnancies _____congenital anomalies

PERSONAL AND SOCIAL HISTORY

Patient's:
Educational attainment: _____________________ Employment: ___________________________________
Source of income (if unemployed): ________________________________________________________________
Smoking: ____yes ____no If yes, ____# sticks per day ____when started? ____when stopped?
Alcohol: ____yes ____no If yes, ____frequency _____quantity ____when started? ____when stopped?
Illicit drug use: ____yes ____no If yes, ____frequency _____quantity ____when started? ____when stopped?
Husband/Partner's:
Educational attainment: _____________________ Employment: ___________________________________
Smoking: ____yes ____no If yes, ____# sticks per day ____when started? ____when stopped?
Alcohol: ____yes ____no If yes, ____frequency _____quantity ____when started? ____when stopped?
Describe the physical facilities of the household:
Housing: # of household members: _________
House: __concrete __wood others: _______ one storey two storey
__good lighting __good ventilation
Toilet: ___flush type ___pour flush
Water Supply: __deep well __NAWASA others: _______
Drinking water: boiled? yes no
Garbage disposal: segregate? __ yes __ no collected? __yes __no (if yes, when?______________)
Hobbies/Recreation: __________________________________________________________________

MENSTRUAL HISTORY
Menarche: ____________
Describe subsequent menses based on:
_______regularity ________duration ________amount of flow by napkin count
Associated signs and symptoms: ___________________________________________
Medications taken and effect of medication: ___________________________________
Indicate history of menstrual aberrations: _____________________________________

OBSTETRICAL HISTORY : G __ P ___ ( __ __ __ __ )

OB Score – 4 numbers (F-P-A-L)
1st number – pregnancies delivered at term
2nd number – pregnancies delivered prematurely
3rd number – pregnancies that ended before or at 20 weeks AOG
 4th number – number of living children
If multigravid:
Number of Date AOG Manner of Place of sex BW Present Complication
pregnancies delivery delivery/ status s
attendant at birth (living?)
G1
G2
G3
G4
G5
Under complication, specify if fetal or maternal (antepartum, intrapartum, postpartum)
If (+) CS delivery, indicate 1-normal order (primary, repeat), 2- type of incision (Low Transverse, Classical), 3- indications
(specify)

GYNECOLOGICAL HISTORY
Infections: ___________________________
Disease & Surgery pertaining to the female repro tract (including breast: __________________________________________
Pap smear with dates and results: ________________________________________________________________________

SEXUAL HISTORY
Coitarche: ________________
Number of lifetime sexual partners: _________________
Regularity: _______________________________ Satisfaction: ______________________________
Associated signs and symptoms (always ask for post coital bleeding): ______________________________
Date of last sexual contact: _______________________

CONTRACEPTIVE HISTORY
Type of contraceptive used: ___________ Generic/brand name: _________________
Duration of use: ____________________ Reason for choice: __________________
Satisfaction with method: _____________ Effectiveness of method: ______________
Undesirable side effect: ______________
If already stopped, Date?: _____________ Reason for discontinuance of the method: ________________

Type of contraceptive used: ___________ Generic/brand name: _________________

Duration of use: ____________________ Reason for choice: __________________
Satisfaction with method: _____________ Effectiveness of method: ______________
Undesirable side effect: ______________
If already stopped, Date?: _____________ Reason for discontinuance of the method: ________________

Type of contraceptive used: ___________ Generic/brand name: _________________

Duration of use: ____________________ Reason for choice: __________________
Satisfaction with method: _____________ Effectiveness of method: ______________
Undesirable side effect: ______________
If already stopped, Date?: _____________ Reason for discontinuance of the method: ________________

HISTORY OF PRESENT PREGNANCY

LNMP= “Kailan ho ang unang araw ng huling regla ninyo?” _________________________
PMP= __________________________
EDC= __________________________ AOG= __________________________
Quickening (date: day or week of the month, year): ____________________________________

 Narrate symptoms, physiologic changes of pregnancy

 Must include in the last paragraph details of the Prenatal History
___ months PTC (___weeks AOG), the patient missed her regular menstrual period
___ months PTC (___weeks AOG), the patient experienced:

PRE-NATAL HISTORY
Who did and Where Prenatal Care is being done?
When is the first and last consult?
How frequent is the Prenatal Check-up?
Laboratories done
Medications: Prenatal/Immunizations given
Part of the ‘History of Present Pregnancy’if no complaint.
This will be the last part of HPP.
A separate entry if (+) complaint
Always ask for the ff information every PNCU (PreNatal Check Up):
Signs & symptoms experienced by the patient
Focus on “Danger Signals of Pregnancy”
Place of previous consult, weight, BP, FHT, etc
Medications prescribed:
Multivitamins/ Prenatal milk
Folic acid supplement
Iron supplement
Calcium
Immunizations:
Tetanus Toxoid
 Hepatitis B
Influenza
Pneumococcal
Laboratory tests requested:
CBC, platelet count
Blood typing
HBsAg
VDRL / RPR
HIV Testing
Ultrasound (date done)
NOTE!!!
If the chief complaint of the patient is not for the regular prenatal check up but for a medical or surgical condition, the HISTORY OF
PRESENT PREGNANCY will instead be HISTORY OF PRESENT ILLNESS. It shall deal on the complaint, when it started, the
signs and symptoms experienced by the patient and any prior consult or treatment done until the patient came for consult. This will
be followed by the PRENATAL/ANTENATAL HISTORY.

HISTORY OF PRESENT ILLNESS

Conditions:
Current Medical / OB complaint/problem
Abnormal laboratory result
Narrate circumstances about the complaint/problem
Prenatal History will be a separate entry
_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
Associated symptoms? ___________________________
_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
Associated symptoms? ___________________________
_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
Associated symptoms? ___________________________
REVIEW OF SYSTEMS
Careful to include symptoms only, entries which consist of PE findings should not be placed here! ALWAYS ask for the
danger signals of pregnancy.

General ___weakness (___%) ___loss of appetite__low-grade fever __weight loss (___%)

___easy fatigability
Integument ___wound ___rashes ___erythema ___pallor ___clubbing of nails
___hyperpigmentation ___hypopigmentation ___mass
Head & Neck ___stiffness ___headache ___distension of veins ___mass ___dizziness
___swelling
Eyes ___pain ___redness ___corrective lenses ___discharge ___ineteric sclera
Ears ___otalgia ___vertigo ___tinnitus ____difficulty in hearing
Nose & Sinuses ___watery discharge ___epistaxis ___obstruction

Mouth & Throat ___toothache ___hoarseness ___dysphagia ___ulcers ___tongue fasciculation

___sore throat
Respiratory ___cough ___dyspnea ___hemoptysis ___tachypnea ___pleuritic chest pain
___greenish phlegm
Cardiovascular ___angina ___dyspnea ___palpitations ____orthopnea __paroxysmal nocturnal dyspnea
GIT ___anorexia ___nausea ___vomiting ___diarrhea ___abdominal distention
___abdominal pain ___ constipation ___melena ___hematemesis ___hematochezia
___retching
GUT ___frequency ___nausea ___polyuria ___oliguria ___nocturia ___dysuria
___flank pains ___palpable mass
Vascular ___claudication ___ulcers
Hematologic ___easy bruising ___easy bleeding ___pallor
Endocrine ___polyuria ___polyphagia ___polydypsia ___diaphoresis ___heat/cold intolerance
MSS/ ___fractures ___joint pains ___edema
Extremities
Nervous System ___seizures ___syncope ___tremors ____one-sded weakness ___slurring of speech
___headache

Autonomic ___fecal incontinence ___urinary incontinence

Deficiency

PHYSICAL EXAMINATION
GENERAL SURVEY:
Development: ___poorly ___fairly ___well
Nutrition: ___poorly ___fairly ___well
Consciousness: ___conscious ___comatose ___drowsy ___stuporous
Coherence: ___coherent ___incoherent
Oriented to: ___time ___place ___person ___dyspneic ___tachypneic
Cardio-respiratory distress: ___mild ___moderate ____severe
Orthopneic: ___no ___yes Relieved by: ____ pillows
___bedridden ___weak but ambulatory ___ambulatory

VITAL SIGNS:
BP= ________ Pre pregnancy weight= ________
HR= ________ Present weight= _____________
PR= ________ Height= ____________________
Temp= ______ BMI= ________

HEENT
Chloasma or melasma or mask of pregnancy
Conjunctiva – color
Epulis

CHEST AND LUNGS

Inspection:
Symmetrical chest: __yes __no
Deformities: __pectus excavatum __pectus carinatum __kyphosis __scoliosis
Chest expansion: ___symmetrical ___local lagging
Use of accessory muscle:__yes ___no
 AP:transverse diameter: ________
Assoc. extra-pulmonary findings: __clubbing __facial puffiness __prominent veins(anterior chest wall)
Palpation:
Tactile fremitus: ___equal ___increased (left/right) __decreased (left/right)
Percussion:
__ hyperresonant (if yes, in what areas?___________________)
__ resonant (if yes, in what areas?___________________)
__ dull (if yes, in what areas?___________________)
Relative Relative Relative location Examples
intensity pitch duration
Flatness Soft high Short Thigh Pleural effusion
Dullness Medium Medium Medium Liver Lobar pneumonia
Resonance Loud Low Long Normal lung Chronic bronchitis
Hyperresonanc Very loud Lower longer None Emphysema,
e pneumothorax
tympany loud High Gastric air Large pneumothorax
bubble

Auscultation:
__ normal breath sounds:
___Bronchial
___Vesicular
___Bronchovesicular
___Tracheal

Breath sound Duration of sounds Intensity of Pitch of Location where normally heard
expiratory sounds expiratory sound
Vesicular Inspiratory sounds last longer Soft Relatively low Over most of the lungs
than expiratory ones
Bronchovesicular Inspiratory and expiratory Intermediate Intermediate Commonly in the 1st and 2nd ICS
sounds are about equal anteriorly and between the scapulae
Bronchial Expiratory sounds last longer Loud Relatively high Over the manubrium, if heard at all
than inspiratory ones.
Tracheal Inspiratory and expiratory Very loud Relatively high Over the trachea in the neck
sounds are about equal.
__ adventitious sounds sounds:
___crackles (Short (less than 12-15 msec), discontinuous, explosive sound, primarily an inspiratory sound)
___wheezing (Continuous sound of musical quality, high-pitched, primarily expiratory)
___rhonchi (Low-pitched, snoring quality, continuous, early expiratory)
___stridor (High-pitched, continuous, purely inspiratory, similar to wheezing except that its inspiratory)
__ decreased breath sounds (left/right)

BREASTS
Breast changes in pregnancy
Venous prominence
Darkening of the nipples and areola
Enlargement of the circumlacteal sebaceous glands of the areola (Montgomery tubules)
Colostrum secretion

HEART:
Inspection
Precordial bulgge: ___present __absent
Point of Maximal Impulse: ___________________ (area of the cardiac surface that maximally pulsates)
(normally at or medial to the left midclavicular line in the 5th or possibly the 4th ICS)
Palpation
Apex Beat:
Heaves: ___present ___absent (If present, location? ________)
Thrills (a palpable murmur): ___present ___absent (If present, location? ________)
Percussion
Heart span: _____ ICS to _____ ICS (cardiac area of dullness from the point of reference (midsternal line)
Auscultation
Rate: ___Normal (60-100bpm) ___Bradycardia (<60bpm) ___Tachycardic (>100bpm)
Rhythm: ___regular ___irregular (report regularly irregular or irregularly irregular)
Heart sounds: S1 > S2: ___base __apex S2 > S1: ___base __apex
Presence of S3 and S4: ________
Murmurs: ___yes ___no
intensity (grading):____
Timing: ___________
Character: ___blowing ___harsh ___rumbling ___ejection ___continuous
Location: _________

ABDOMEN:
Inspect: describe striae (color), scars (location, length, hypertrophic vs keloid)
Palpation: FH= _____cm EFW= _____kg
LM1 (Fundal Grip)
Determines what fetal part occupies the fundus
Cephalic presentation: large nodular body representing the buttocks or lower extremities
Breech presentation: hard, freely moveable and ballotable part representing the head
Shoulder presentation/ Transverse lie: empty
 LM2 (Umbilical Grip)
Determines on which maternal side is the fetal back
Fetal back: resistant convex structure
Fetal small parts: numerous nodulations
LM3 (Pawlik’s Grip)
Determines what fetal part lies over the pelvic inlet
If fetal head (cephalic presentation) is not engaged: movable, round, hard body palpated
If lower pole of fetus is engaged, head is fixed.
LM4 (Pelvic Grip)
Determines on which side is the cephalic prominence
In flexion attitude, cephalic prominence is on the same side as the small parts
Auscultation: FHT= ______ bpm located on the ______________, note for regularity.

GENITALIA
EXTERNAL GENITALIA: External look for scars & lesions such as ulcers, varicosities, discharges
SPECULUM EXAMINATION: Describe the shape of cervical os, look for lesions in the transformation zone such as Nabothian
cysts, ulcers, tumors, discharges; results of VIA if done.
INTERNAL EXAMINATION: Describe cervix according to following:
D-ilatation
E-ffacement
P-osition
A-mniotic membranes
P-resentation
S-tation
CLINICAL PELVIMETRY:
Pubic arch: ______________ DC: _____________ S notches: _______________
Side walls: ______________ Spines: __________ BS:_____________________
Sacral inclin.: ____________ Sacral Curvature: ____________________________
BT: ____________________ Coccyx: ____________________________________
ASSESMENT: ( ) Adequate ( ) Doubtful ( ) Inadequate

EXTREMITIES
Look for & describe varicosities, edema, congenital anomalies, if any.

NEUROLOGIC: if warranted
Mental Status:
General behavior:
___normal ___immobile ___hyperactive ___slovenly dressed ___agitated ___quiet ___neat
___dressed appropriately according to age and occasion
Stream of talk: ___normal ___rapid ___slow ___scarce ___verbose
Mood: ____appropriate ___labile ___silent ___euphoric ___hostile ___agitated
Content of Thoughts: ___illusions ___delusions ____paranoia ____misinterpretation ____hyperchondriasis
___auditory/visual hallucination
Intellectual Capacity: ___bright ___average ___dull ___demented ___retarded
Sensorium:
Consciousness: ____awake ____drowsy ____obtunded ___delirious ___stupor ___coma
Attention Span: ____normal ___short
Orientation: ____normal ____disoriented
Memory
Remote: ____good ____poor ____fair
Recent: ____good ____poor ____fair
Immediate: ____good _____poor ____fair
Fund of Information: ____well-informed ____uninformed
Calculation: ____able ___dyscalculia
Insight/Judgment _________________

Cranial Nerves:
I: able to smell: ____yes ____no
II, III, IV, VI: (already assessed)
V: good masseter and temporalis tone, V1, V2 and V3 equal facial sensation: ____yes ___no
VII: facial symmetry: ___yes ___no can taste on the anterior 2/3 of tounge: ___yes ___no
IX, X: swallow: ____yes ___no, cough: ____yes ___no gag reflex: ____(+) ____(-)
XI: good trapezius tone: ___yes ____no good SCM tone: ___yes ____no
XII: tongue midline: ___yes ___no fasciculations: ___yes ___no

Sensory
 Touch: ___intact ___not intact
Pain: ____intact ___not intact
Vibratory sense: ____intact ___not intact
Position sense: _____intact ___not intact
Romberg: ____intact ___not intact

Motor
Inspection:
Posture/Gait:_______________
Somatotype:________________
General Activity:_____________
Tremors (distribution type):______________
Involuntary Movements:________________
Palpation:
Muscle bulk: ___atrophy ___hypertrophy ___normal bulk
Body symmetry:
Joint malalignments:
Fasciculations:
Muscle tone: ___flaccid ___spastic ___rigid ___normal

Manual Muscle Strength Testing: Reflexes

Deep Tendon Reflexes:

___biceps ___triceps ___patellar ___brachioradialis ___Achilles tendon
Physiologic Reflexes: ___anal wink ___abdominal reflex ___jaw jerk
Pathologic Reflexes:
___Babinski (left/right) ___ankle clonus (left/right) ___snout ___grasp reflex ___palmomental

Cerebellar
Nystagmus: ____(+) ____(-)
Tandem Walk: _____(+) _____(-)
Dysmetria:
Finger to nose: _____(+) ____(-)
Heel to shin: _______(+) ____(-)
Dysdiadokinesia: _______(+) ____(-)
Tandem gait: ______(+) _____(-)
Rebound phenomenon: ______(+) ____(-)

Meningeals
Passive Neck Flexion: ____(+) ____(-)
Kernig’s: ____(+) _____(-) (a positive response is sudden flexion of the knee)
Brudzinski: ____(+) _____(-) (observe for a response- neck flexion)
Higher Cerebral Functions
Aphasia
Expressive (of spoken language): ____(+) ____(-) (name 10 fruits, objects)
Expressive (of written language): ____(+) ____(-) (writing complete sentence, spelling)
Word repetition: ____(+) _____(-) (wala nang pero-pero pa) (no-ifs-and-orbuts)
Apraxia
Ideomotor Apraxia: ____(+) ____(-) (gives direction or requests patient to do a voluntary movement: light a candle)
Dressing Apraxia: ____(+) ____(-) (asks patient to put on hospital gown or jacket)
Constructional Apraxia: ____(+) ____(-) (asks patient to draw any shape ex clock drawing test)
Gait Apraxia: ____(+) ____(-) (asks patient to walk)
Agnosia:
Astereognosia: ____(+) ____(-) (asks patient to identify objects by palpating its texture & form in his hand)
Agraphognosia: ____(+) ____(-) (asks patient to identify numbers drawn by examiner on his palm)
Finger Agnosia: ____(+) ____(-) (asks patient to identify examiner's fingers)
R-L Disorientation: ____(+) ____(-) (asks patient to identify right and left side of body)

NOTE:
 AS MUCH AS POSSIBLE COMPLETE THE PHYSICAL EXAMIANTION
 Indicate if NOT DONE and GIVE THE REASON WHY
 FOR THE EXAMINATION OF THE GENITALIA AND CLINICAL PELVIMETRY, ASK THE RESIDENT OR CONSULTANT PRESENT IN THE WARDWORK.

IMPRESSION:
AGE: ____, G _ P _ ( __-__-__-__ ) Pregnancy uterine, ____weeks AOG, __________presentation, ______ (in or not in) labor,
_____________________ (give the high risk factors, or co-morbid conditions)