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Gujarat Institute of Nursing Education & Research, Ahmedabad Antenatal Performa

This document contains an antenatal form for collecting a patient's medical history and examination findings. It includes sections on the patient's personal details, past medical, obstetric and menstrual history, chief complaints, physical examination, laboratory tests, medications and notes. The form is used to document all relevant information needed to assess and monitor the patient's pregnancy.

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hir
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69 views

Gujarat Institute of Nursing Education & Research, Ahmedabad Antenatal Performa

This document contains an antenatal form for collecting a patient's medical history and examination findings. It includes sections on the patient's personal details, past medical, obstetric and menstrual history, chief complaints, physical examination, laboratory tests, medications and notes. The form is used to document all relevant information needed to assess and monitor the patient's pregnancy.

Uploaded by

hir
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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GUJARAT INSTITUTE OF NURSING EDUCATION & RESEARCH, AHMEDABAD

ANTENATAL PERFORMA

Name of the Patient:


Age: Admission Date:
Registration Number: Cot No.
Address: Doctors Unit:
Religion: Education:
Her Occupation: Income:
Husbands’ Occupation: Special Interest:
Addiction/ Habit: Diet:
Special Liking in Diet: Date of Marriage:
Diagnosis:

MOTHERS’ PAST HEALTH HISTORY:

General health:
Illness:
Accident:
Operation/ Surgery:
Blood Transfusion:
Specific Treatment:
Allergy:
Suffered From:
Veneral Disease: Asthma:
Heart Disease: Diabetes:
Rheumatic Fever: Tuberculosis.
Aids: Any Other:
Lacational History:
Breast feed to previous baby Yes\ No
Failed To breast feed any child: Yes\ No
Note:
PAST OBSTETRIC HISTORY
Place of
Sr Term-
Delivery Child Date Weight
. Gravida / Preterm Aborti- APH/ Perineal Type of
Home/ Live/ of At episiotomy Remark
N Para / Full on PPH Tear Delivery
Institu- Dead birth Birth
o term
tion

PRESENT OBSTETRICAL HISTORY


MENSTRUAL HISTORY
Menarchy: Duration:
Regularity: Flow of Bleeding:
Gravida: Para:
L.M.P. E.D.D.:
Period of Gestation:
Height: Weight:
Immunization:
1st Dose, Month:
2nd Dose Month;
CHIEF COMPLAINS:
Sr.No. Problems Advice Remark

ANTENATAL EXAMINATION:
GENERAL EXAMINATION:
General Appearance:

General Nutrition:
Height: ------------- Cm.
Weight: -------------Kg.
Arm Circumference: -----------------------Cm.
Blood Pressure: ---------------- Mm/Hg.
Temperature: ----------- /F
Pulse: ----------- /Min.
Respiration: ------------- /Min.
Eye:
Pallor:
Tongue, teeth, gums, and tonsils:
Neck:
Oedema of legs:
Breast examination:
-Right breast-
-Left breast:
Varicose vein:
Vaginal discharge:
Bleeding:
Sleep:
Note:

OBSTETRICAL EXAMINATION:

Abdominal Inspection:

Abdominal Palpation:
– Abdominal Girth:
– Fundal Height:
– Fundal Palpation:
– Lateral Palpation:
– Pelvic grip Palpation:
– Pawlik grip palpation:
CONCLUSION:
– Presentation:
– Position:
– Condition of Presenting Part:
AUSCULTATION:
– F.H.S.
– Located Site:
LABORATORY INVESTIGATION:
Urine
– Albumin:
– Sugar:
Blood:
– Hb:
– Rh Factor:
– Group:
– Hbs Hg:
Stool:
SPECIAL INVESTIGATION:

Sr.
Investigation Examination Reason Report
No.

MEDICATION

Sr. Name Of Contra- Side


Dose Route Action Remark
No. Drug Indication Effect

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