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2 0N1 9
I. Past History:
A. Maternal History
Gravida Para _____
Pre-natal check-up (for this pregnancy baby) Yes No
Where:
No. of Prenatal Visit: _________________
Illness during this pregnancy (specify): ______________________________________________________
X-ray exposure: At what month/trimester of pregnancy: ________________
Drug Intake: Yes No Nature of drug: _____________________________________________
Reason for taking the drug: ______________________________________________________________
When (trimester) Nature of drug: _____________________________________________
B. Birth History:
Full Term Premature Weight Length
Place of Birth: Hospital Home Others
Assisted by: Physician Nurse Nurse Midwife Others
Manner of delivery: Cesarean Forceps Vaginal
Indication
Presentation: Cephalic Breech Others
D. Neonatal Complications
None Incubator care
Cyanosis Jaundice
Prematurity Difficult respiration
Others (ex. Congenital anomalies):
E. Past Illness (check if applicable)
o Cough
o Colds
o Diarrhea
o Fever
o Measles
o Parasitism
o Skin disease
o Others:
Hospitalization: No Yes
If yes, where:
For what :
When:
Duration:
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