Ajoc, Jenny Juniora
Aquino, Patricia Gilrose
Barreda, Mary Anne
BSN 211
Surname
Date of Admission
Marital Status
Educational Attainment
❏ Elementary undergraduate
❏ Elementary graduate
❏ High school undergraduate
❏ High school graduate
❏ College undergraduate
❏ College graduate
Other: _____________
History of TTD Immunizations
Dose
❏ First (During pregnancy) ____________
❏ Second (4-6 weeks after) ____________
❏ Third
❏ Fourth
❏ Fifth
Have you been Hospitalized
before:
□​YES
If yes, when was the last
hospitalization?
_________________________
Reason:
_________________________
□ ​NO
Bartolome, Zandhreen November 12, 2019
Bonotan, Jhansi Johore R. Prof. Florendo
Personal Data
First Name Middle Name
Weight Height Contact Gender.
No.
Name of spouse Age Birthday Ethnic Group
Religious Orientation Address
Are you a member of the following​? Put a check on the box below if you are a member
of those organizations. If not, check the box and state at the space provided the
member of the family who is a member of the organization and state what type of
benefits you are able to get.
□ GSIS_____________ □ SSS______________ □ Pag-Ibig__________
□ PhilHealth________ □ Iba pa ___________
Health History
Do you have any current medical Do you have members of the
conditions? family, or a line in your family
Date that have:
❏ Asthma,
❏ Cardiovascular diseases, ❏ Asthma,
❏ Hypertension (high blood), ❏ Cardiovascular diseases,
❏ Hypotension (low blood) ❏ Hypertension (high blood),
❏ Diabetes ❏ Hypotension (low blood)
❏ Anemia ❏ Diabetes
❏ Cancer / Malignancies ❏ Anemia
❏ Goiter ❏ Cancer / Malignancies
❏ Goiter
❏ Other__________
❏ Other__________
Are you currently taking maintenance Have you travelled locally (within the
medicines/drugs? Philippines) or in foreign countries?
Please state the year and country or
□​YES locality:
If yes, What for? □​YES
_______________________________________ ______________________________
_______________________________________ ______________________________
□​NO □​NO
Have you undergone Surgery before:

□ ​YES (If yes, When was your recent surgery and reason for the surgery and type of
surgery:____________________________________________________________________________________________
__________________________________________________________________________________________________;

If multiple surgeries, list down the type of surgery undergone:

___________________________________________________________________________________________________
___________________________________________________________________________________________________

□ ​NO

How many times Did you get
pregnant?
Obstetric Data
Do you have children Have you experienced any Have you experienced or have
that were born under miscarriages or abortions? delivered children that are
37 weeks? twins, triplets, etc?
□​Yes (if yes, how many
□​Yes (if yes, which times?) □​Yes (if yes, how many times?)
pregnancies were ____​____________ __________________________
they?) _______________ __________________________
___________________
___________________ □​No □​No

□​No

Name of Child Age Birth defects (if any)

1. ________________________________________ __________ ____________________
2. ________________________________________ __________ ____________________
3. ________________________________________ __________ ____________________
4. ________________________________________ __________ ____________________
5. ________________________________________ __________ ____________________
6. ________________________________________ __________ ____________________
7. ________________________________________ __________ ____________________

Have you experienced any illnesses or complications Did you take any drugs, medications, supplements, during any
during any of the pregnancies? of the pregnancies?

□​Yes (if yes, what was it?) □​Yes (if yes, what was the medication/s and purpose?)
________________________ ___________________________________________
□​No □​No

Did you smoke during the pregnancy/ies? Did you consume any alcohol during the pregnancy/ies?

□​Yes □​Yes
if yes, how many sticks of cigarettes do you smoke in a if yes, how much? ____________________________________
day?) ________________________________________ What kind of alcoholic drink? ___________________________
What triggers you to smoke? _____________________ What triggers you drink? ______________________________

□​No □​No
 History of 1st Trimester
Method of Recall of General Bleeding or Pain Vaginal Discharges Did you feel and
Confirmation Health (Check as experience the
many as followed or Did you feel pain? Have you following:
□​LMP observed) □​Yes experienced finding
□​Pregnancy Test □​No vaginal discharges □​Nausea
□​Blood Test □​Energetic On a scale of 1-10 that are: □​Vomiting
□​Internal □R​esponsive how would you rate □​Clear □​Loss of appetite
Examination □​Tired your pain? (​10 ​is the □​White Thin or Do you wake up in
□ others: □​Malaise (a general MOST PAINFUL ​and ​1 Sticky the morning due to
________ feeling of discomfort) as ​NOT PAINFUL​) □​White cloudy and these symptoms?
□​Lethargic _________________ thick □​Yes
□​Retarded □​White and Smelly □​No
□​Restless Where is the pain □​Grey
located? □​Brown How frequent do you
_________________ □​Red feel these symptoms?
Any deviations in
_________________ □​Pink _________________
vital signs (Blood
When does the pain □​Green _________________
pressure, occur and How
respiration rate, □​Yellow
frequent does it How many times a
pulse rate, or happen? day do you
temperature?)? _________________ experience these
_________________ symptoms?
□​Yes (if yes, please _________________ _________________
describe) ________________
________________ How long have you
experienced these
□​No symptoms?
__________________
__________________

How many glasses of In an estimation, how Drug History or Vaccination Investigation

water did you drink in much mL did you Prescribed
a day? excrete per Medication Are You complete Have you Undergone
__________________ urination? with your vaccines the following tests?
__________________ _________________ List down the before getting (If yes please specify
_________________ following drugs or pregnant? the date)
How many times did _________________ medicine used ​FOR □​Yes
you urinate in a day? TREATMENT □​No □​Ultrasound
__________________ What was the color PURPOSES: __________________
__________________ of your urine? And __________________ Have you attained □​Blood Test
did it have an odor? __________________ doses or booster of __________________
Did you hold your Please specify. __________________ the following: □​Urine Test
urge to urinate? _________________ __________________ □​MMR __________________
□​Yes _________________ __________________ □​Tdap
□​No _________________ __________________
_________________ __________________
Did you have __________________
difficulty in urinating? Did you feel a __________________
□​Yes burning sensation __________________
□​No when you urinate? __________________
□​Yes __________________
□​No __________________

Prenatal check up history

Did you attend prenatal check ups during the first trimester?
□​Yes (if yes, where?) _______________________________
(How often?) _________________________________
□​No

Please describe the teachings / interventions done by the healthcare professionals during the first trimester
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
 History of 2nd Trimester
History of Fetal Found symptoms: Vaginal Discharges UTI
Movement
□​Extreme Fatigue/ extreme Have you experienced □​A burning feeling when
When did you first dizziness finding vaginal you pee.
feel the baby move? □​Lethargic / Easily gets tired discharges that are: □​A frequent or intense urge
__________________ □​Pale skin/ Pale lips/ Skin pallor of □​Clear to pee, even though little
__________________ hands and feet are pale. □​White Thin or comes out when you do.
□​Mild to severe cramps Sticky □​Cloudy, dark, bloody, or
How frequent did you □​Pain in your back or abdomen □​White cloudy and strange-smelling pee.
feel the baby move □​Loss of pregnancy symptoms, such thick □​Feeling tired or shaky.
within one minute? as nausea or vomiting □​White and Smelly □​Fever or chills (a sign that
__________________ □​White-pink mucus. □​Grey the infection may have
__________________ □​Brown reached your kidneys)
□​Passing tissue or clot-like material.
□​Nausea and vomiting with pain. □​Red □​Pain or pressure in your
How many times do
□​Sharp abdominal cramps. □​Pink back or lower abdomen.
you feel the baby
□​Pain on one side of your body. □​Green
move, in a day?
__________________ □​Dizziness or weakness. □​Yellow
__________________ □​Pain in your shoulder, neck, or
rectum. □​No discharges

Any deviations in vital signs

(Blood pressure, respiration rate,
pulse rate, or temperature?)?

□​Yes (if yes, please describe)

________________
□​No

Prenatal check up history

Did you attend prenatal check ups during the second trimester?
□​Yes (if yes, where?) _______________________________
(How often?) _________________________________
□​No

Please describe the teachings / interventions done by the healthcare professionals during the first trimester
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

History of 3rd Trimester

During this term, Vaginal Discharges Bleeding Urination Elimination In an estimation, how
have you been □​Yes many glasses of
Prescribed with □​No Have you How many glasses of water do you
medications due to: Have you experienced bleeding water did you drink in urinate?
experienced finding or spontaneous a day? _________________
□​Hypertension vaginal discharges (sudden) bleeding? __________________ _________________
□​Hypotension that are: □​Yes __________________ _________________
□​Diabetes □​Clear □​No
□​Epilepsy □​White Thin or If yes, when did it How many times do How many times do
Sticky started to happen you urinate in a day? you urinate in a day?
□​White cloudy and and for how long __________________ _________________
thick have you __________________ _________________
□​White and Smelly experienced it.
□​Grey Please specify the Do you hold your What is the color of
color and the urge to urinate? your urine? And, do it
□​Brown
□​Red estimated amount of □​Yes have an odor? Please
□​Pink blood. □​No specify.
_________________ _________________
□​Green _________________
_________________ Do you have difficulty
□​Yellow _________________ in urinating? _________________
 _________________ □​Yes _________________
_________________ □​No _________________
_________________ _________________
_________________ Do you feel a burning _________________
_________________ sensation when you _________________
_________________ urinate? _________________
_________________ □​Yes _________________
_________________ □​No
Hospital Stays Prenatal check up history

Have you Did you attend prenatal check ups during the third trimester?
experienced, during □​Yes (if yes, where?) _______________________________
pregnancy, hospital (How often?) _________________________________
stays? □​No
□​Yes
□​No Please describe the teachings / interventions done by the healthcare professionals during the
If yes, please specify first trimester
the reason for _____________________________________________________________________________
hospital stay: _____________________________________________________________________________
□​For Treatment _____________________________________________________________________________
□​For Surgery _____________________________________________________________________________
□​Other reason: _____________________________________________________________________________
_________________ _____________________________________________________________________________
_________________
_________________
_________________
_________________

Postpartum History
During labor
❏ clean linen
❏ clean hospital gown
When did you feel the onset / start of labor? ___________
❏ equipment for washing perianal area (soap, clean
water supply, sterile gauze, betadine)
In a scale of 1 to 10 (​10 ​being the ​MOST PAINFUL​ and ​1
❏ proper segregation of materials
being ​NO PAIN​) how would you rate your labor pain?
❏ gloves
________________________________________________
❏ catheter
❏ proper light source
What did the nurse do to manage your pain?
❏ proper heat source
________________________________________________
________________________________________________
Did the health care professionals perform “unang yakap”?
Did the nurse / primary health care provider explain the
□Yes
difference between true labor and false labor? □No
□Yes
□No Did they remove the vernix (white matter upon
birth)?
Were you, at any point, asked to walk to make the □Yes
pain go away? □No
□Yes □ cannot recall
□No
Did they immediately bathe the infant after?
Check all that the facility / hospital was able to □Yes
provide: □No
❏ Fetal heart monitor □ cannot recall
❏ anesthetics
How long (from onset of birth, in minutes) before they
❏ Gynecological chair
gave you the infant to breastfeed? _______________
❏ surgical materials for lithotomy
❏ blood pressure machine and stethoscope Did they provide proper breastfeeding education?
❏ thermometer / temperature monitoring □Yes
❏ drop light □No
❏ oxytocin injection please describe:_____​___________________________
❏ drop light (for infant) _______________________________________________
❏ individual beds for infants _______________________________________________
 Postpartum bleeding
Have you experienced postpartum bleeding?
□Yes
□No
Number of pads you have consumed within an hour
__________________________________________
What did the nurses / primary health care provider do
to manage your postpartum bleeding?
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Have you received patient education about
postpartum bleeding?
□Yes
□No
Were there any complications regarding postpartum
bleeding?
□Yes (if yes, please specify) ____________________
□No
Fever
Have you experienced fever?
□Yes
□No
If yes, for how long, and note when the fever started?
___________________________________________
Please describe the treatment or interventions done
by the nurses and other health care professionals did
to treat your fever (if applicable).
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Medication administration
Were you prescribed with medication after giving birth?
□Yes
□No
If yes, please specify below the medications.
1. ________________________________________
2. ________________________________________
3. ________________________________________
4. ________________________________________
5. ________________________________________
Did these medications help in resolving what
problem they were intended for?
□Yes
□No
Did the nurse / primary health care provider explain
or educate you about these drugs prior to
administering them?
□Yes
□No
Postpartum depression
Are you aware of postpartum depression?
□Yes
□No
Did you suffer from postpartum depression?
□Yes
□No
Where did you hear this? _________________
What were the interventions / patient education
provided to you? (if applicable).
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Do you remember any findings / deviations in the ff. areas?

General Survey and

Integumentary Head to Neck Chest Abdomen Extremities
System

_______________ _______________ _______________ _______________ _______________

_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________ _______________

Were there any complications or errors in the nurses / health care professionals part?
□Yes
□No
if yes, please describe:
__________________________________________________________________________________________
__________________________________________________________________________________________

Were there any long term physical, or mental damages emerging from labor experiences?
□Yes
□No
if yes, please describe:
__________________________________________________________________________________________
__________________________________________________________________________________________

END
Thank you for participating in this interview. God bless!
References:

Webber, J., Kelly J., (2019). Health Assessment in Nursing 6​th​ Edition; ​Nursing Assessment of Special Groups:
Assessing Child bearing Women p. 691-717. ​Hong Kong: Wolters Kluwer.

Pillitteri, A., Silbert-Flagg,J, (2019). Maternal and Child Health Nursing: Care of the Childbearing and
Childbearing Family 8​th​ edition Volume 1. ​Nursing Care During Normal Pregnancy and Care of the
Developing Fetus: Assessing Fetal Well Being p.191-199.​ Hong Kong: Wolters Kluwer.

Pillitteri, A., Silbert-Flagg,J, (2019). Maternal and Child Health Nursing: Care of the Childbearing and
Childbearing Family 8​th​ edition Volume 1. ​Nursing Care Related to Assessment of a Pregnant Family
p.231-236​.Hong Kong: Wolters Kluwer.