7/29/2019 OB Template
1/4
SUrname First Middle
Attending Physician
DR. PADILLA
Date
Age Sex Status
RM. No Hosp No.
GENERAL DATA
NAME _________., AGE ________, G_ P_ (____), Status________,
Race_________,Religion_____________, born
on_______________________, presently residing at
__________________________________, and was admitted in our
institution on____________ at ___________ due to
________________________________________________.
PAST MEDICAL HISTORY
Patient is a known
_______________________________________________________________,
maintained with_______________________________________________.
Patient took her medication during _______________________________.
Patient isa non-diabetic? non-asthmatic? no heart, no kidney and no
history of malignancy? Patient had no allergies to food and
drugs?
FAMILY MEDICAL HISTORY
Patients family has a history of Heredofamilial
diseasesPaternalMaternal
PERSONAL AND SOCIAL HISTORY
The patient is a ______________ graduate degree in
____________________. She works as
_______________________________.smoker, alcoholic beverage drinker.
illicit drugs used.
MENSTRUAL HISTORY
She had her menarche at age of __, with subsequent menses
occurring at _______________intervals (28-30 days cycle), lasting
for __days, consuming ________________ soaked pads per day, with
occasional episodes of dysmenorrheal? and medication
taken____________.
GYNECOLOGIC HISTORY
Patient had her first coitus at the age of ___ with ____sexual
partner/s whom she is married for ____ years named
____________.Patient had history of postcoital bleeding, or
dyspareunia? Patient had history of oral contraceptive use?
___________________ Pap smearwas done last______________ which
revealed ____________________. Patient was advised
___________________.
OBSTETRIC HISTORY:
Patient is a G_P_ (_____)Year/ Term/preterm? at weeks AOG/ via
NSD/CS 2ndary to ?/ where?/ feto-maternal complications?/ babys
weight?
G1G_G_G_G_G? present pregnancy
LMP: _________________
AOG: _________________EDC: ___________________
7/29/2019 OB Template
2/4
ANTENATAL HISTORY
At ____ weeks amenorrhea, patient suspected pregnancy. Pregnancy
test was done at home which revealed positivresults. Patient had no
associated symptoms noted such as vomiting, headache, epigastric
pain and nausea. Patient had nmedications taken nor consult
done.
At _____ weeks age of gestation, patient had het first pre-natal
check up where complete blood count and urinalyswas requested and
done which revealed normal results. Internal examination was also
done which revealed uterus slightenlarged.
At __ age of gestation, patient had her follow-up check up
At __ weeks age of gestation, patient had her follow-up
Subsequent pre-natal check ups were unremarkable
At ____ weeks age of gestation, patient had her follow-up check
upSubsequent pre-natal check ups were unremarkable.
At _____ weeks age of gestation, patient had her pre-natal check
up
Few hours prior to admission, patient was subsequently admitted
for the contemplated procedure, hence admission.
REVIEW OF SYSTEM
General: no loss of appetite, no weight lossSkin: no scars, no
lesionsHead: no headache, no dizzinessEye: no discharge, no
blurring of visionEar: no tinnitus, no dischargeNose: no colds, no
epistaxisMouth and throat: no gum bleeding no hoarseness, no
dysphagiaRespiratory: no cough, no difficulty of
breathingCardiovascular: no palpitation, no orthopneaGIT: no
constipation or change in bowel habitsGUT: no frequency, no tea
colored urineMusculoskeletal: no spasm, no joint painsCNS: no
numbness, no seizures, no loss of consciousness
PHYSICAL EXAMINATION
General Survey: The patient is ambulatory, conscious, coherent
and not in cardio-respiratory distress
BP: ________ CR: _________ RR: __________ T: _____________
SHEENT: anicteric sclerae, pink palpebral conjunctiva; no
nasoaural discharge; no tonsillopharyngeal congestion; no
cervicalymphadenopathy
Chest/Lungs: Symmetrical chest expansion, no retraction, clear
breath sounds
Heart: Adynamic precordium, normal rate, regular rhythm, no
murmur
Abdomen: Flabby, normoactive bowel sounds, soft, non-tender
Fundic Height
___________FetalHeartTone ____________EstimatedFetalWeight
_____________LM1 ______ LM3 _________LM2 ______ LM4 _________
Extremities: grossly normal, no cyanosis, with full and equal
pulses, with non-pitting edema Grade II
