Date

SUrname

First Attending Physician

Middle

RM. No Age Sex

Hosp No. Status

GENERAL DATA

DR. PADILLA

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 is a 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 diseases Paternal Maternal 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 smear was 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? G1 G_ G_ G_ G_ G? present pregnancy LMP: _________________ AOG: _________________ EDC: ___________________

ANTENATAL HISTORY
At ____ weeks amenorrhea, patient suspected pregnancy. Pregnancy test was done at home which revealed positive results. Patient had no associated symptoms noted such as vomiting, headache, epigastric pain and nausea. Patient had no medications taken nor consult done. At _____ weeks age of gestation, patient had het first pre-natal check up where complete blood count and urinalysis was requested and done which revealed normal results. Internal examination was also done which revealed uterus slightly enlarged. 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 up Subsequent 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 loss Skin: no scars, no lesions Head: no headache, no dizziness Eye: no discharge, no blurring of vision Ear: no tinnitus, no discharge Nose: no colds, no epistaxis Mouth and throat: no gum bleeding no hoarseness, no dysphagia Respiratory: no cough, no difficulty of breathing Cardiovascular: no palpitation, no orthopnea GIT: no constipation or change in bowel habits GUT: no frequency, no tea colored urine Musculoskeletal: no spasm, no joint pains CNS: 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 cervical lymphadenopathy 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