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Date &Time:

Patient ID:

Attending Physician:

Age:

Birth Date:

Name:
Gender:
Chief Complaint:

Religion:

History of Present Illness

Past Medical History

Medications:

Allergies:

Adult Illnesses:
HTN (Years, Highest BP, Usual BP):

DM (Years, Complications):

Asthma (Since, last attack):

PTB (When, Treatment):

Cancer:

MI:

Thyroid Disorder:

CKD (Stage):

CHF
Childhood Illnesses
Immunizations (Tetanus shots)
Medications:
Smoker (sticks per day, years, stopped):

Travel History

Alcohol beverage drinker (bottles per week):

Illicit Drug Use:

Family History

DM:

Stroke:

Thyroid:

HPN:

Asthma:

PTB:

Cancer:

Others:

Personal and Social History

Smoker (sticks per day, years, stopped):

Travel History

Alcohol drnker (bottles per week):

Illicit Drug Use:

Family History
HPN:

DM:

Stroke:

Thyroid:

Asthma:

PTB:

Cancer:

Others:

Menstrual History

Sexual History

Menarche

LMP

Age first coitus

Regular? Duration cycle?

PMP

Number sexual partners

Duration bleeding:

Menopause

History of dyspareunia, post coital bleeding, STD:

Amount:
OB History

OB SCORE: G

Gravida, Year, AOG, Outcome, Weight, Procedure

Physical Examination

AOG
EDC

Vital Signs

BP:

Anthropometric
Abdomen
Leopold
s
Pelvic Exam

Weight:

Fundic Height:

RR:

Height:

BMI:

FHR:

LM1
LM3

HR:

LM2
LM4

Estimated Fetal Weight:

Speculum:

Internal Examination:
Physicians in charge
Admitting Diagnosis:

Plan:

Attending:

Resident:

Temp