ASUHAN KEBIDAN DAN KANDUNGAN

I. BIODATA
Nama pasien : ........................................ Nama suami : ...........................................
Umur : ........................................ Umur : ...........................................
Agama : ........................................ Agama : ...........................................
Pendidikan : ........................................ Pendidikan : ...........................................
Pekerjaan : ........................................ Pekerjaan : ...........................................
Penghasialan : ........................................ Penghasialan : ...........................................
Alamat : ........................................ Alamat : ...........................................
II. ANAMNESA
Tanggal : .......................... Jam : ....................
1. Keluhanutama :
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2. Riwayat Kesehatan Keluarga

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3. Riwayat Penyakit yang di derita ibu :
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4. Riwayat Alergi dan Ketergantungan :
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5. Riwayat Kebidanan :
a. Riwayat Haid :
Menarche : ................... tahun
Siklus : ................... hari
Lama : ................... hari
HPHT : ...................
HPL : ...................
Teratur : Ya / Tidak
Dismenore : Ya / Tidak
b. Darah putih : Ya / Tidak
Lama : ................... HARI
Warna : ...................
Bau : Ya / Tidak
Gatal : Ya / Tidak
c. Riwayat Kehamilan, Persalinan, dan Nifas yang lalu :
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d. Riwayat KB : Ya / Tidak
Jenis KB : Pil / Injeksi / UD / Tubektony
Lama : ...........................
Alasan : ..........................................................................................................
e. Riwayat Kehamilan Sekarang :