Name: St.

Luke’s Medical Center - Quezon City

Age: Birth date: Department of Obstetrics and Gynecology
PIN: Database

Room PE​:
AMD ☐ ​Conscious, coherent, not in CPD
☐ ​Admission​ ☐ ​Referral _______ sclerae, _____________ conjunctivae
Patient is a _____-year old G__P__ (___-___-___-___) Supple neck, _____ CLADs
☐​Adynamic precordium, normal rate regular rhythm
☐​Symmetric chest expansion, clear breath sounds
CC​:
☐​Abdomen
PMHx​:
☐​HPN (____) HPB___ UBP____ on _______
☐​DM (____) on
☐​BA LA: ________ ( )Meds SE:
☐​Thyroid disease IE: ___% | ____cm | _____ | ( ) bag of waters
☐​Others:
Previous Sx: ☐​No edema, full pulses

Allergies:
PSHx​: Plan:
☐​Smoker: ____ pack years ​☐​Alcoholic Beverage Drinker Admitting orders:
FHx: ☐ NPO on
☐​HPN ​ ​DM
☐ ​ ​BA
☐ ​ ​CA
☐ ☐ IVF:
☐​Others: ☐ Ancillary:
☐ Therapeutics:
☐ ​Antibiotics:
MHx​: ☐ Referral:
MIDAS: ____y.o. / __regular / ____days / _____ppd /
( ) symptoms Anesthesiologist:
LMP: ___________________ PMP: ___________________ ☐ ​Bowel preparation:
Gyne Hx​: ☐ ​Blood Transfusion Consent
Coitarche: _____ y/o / ____sexual partner(s) ☐G ​ eneral Procedure/Consent
☐ ​Post-coital bleeding ​ ​Dyspareunia
☐ ☐ ​Clearance
☐ ​OCP: ____________ ☐ ​Database + Problem list w/ sign
☐ ​Latest Pap Smear: ________ Results:
OBHx​: G__P__ (___-___-___-___) Laboratory/Work-ups done:
Year AOG Type Sex Weight FMC CBC (___/___)
G1 Hgb: ___ Hct: ___ PC: ___ WBC: ___ N: __ L: __ M: __
G2 E: __
G3 Urinalysis: (___/___)
G4
G5 Hep B (___/___): ____ Blood Type:
G6 Others:
HPI: ​UTZ (___/___):