OBSTETRICS HISTORY TAKING
Typed & enriched version
This document is a clean, typed presentation of the uploaded handwritten obstetric history-taking notes. Blank
fields and alternative options have been retained rather than inventing patient-specific details.
1. IDENTIFICATION DATA
Patient Mrs. ______________________________
Age ________ years
Occupation ______________________________
Husband's name / occupationMr. __________________ / __________________
Obstetric status Gravida ______ Para ______ Living ______ Abortions ______
Residence ______________________________
Socio-economic status ______________________________
Booking / immunization status
Booked / Immunized / Both / __________________
Date of presentation ______________________________
Chief complaint(s) ____________________________________________
2. OBSTETRIC DATING
LMP: ____________________ EDD: ____________________ GA: ____________________
Obstetric code: ______________________________________________
3. HISTORY OF PRESENTING OBSTETRIC COMPLAINTS
Patient presents with ______ months of amenorrhoea with complaints of
______________________________.
For the presenting complaint: onset, duration, severity, relieving factors, aggravating factors,
associated symptoms, and medications used are to be elicited.
Menstrual history: Menarche at ______ years. Cycles were regular / irregular, approximately ______
days, with flow lasting ______ days. About ______ pads/day were used; pads were partially / fully
soaked. Associated with / without lower abdominal pain, backache and clots. LMP:
____________________.
4. MARITAL HISTORY
• Married at the age of ______ years.
• Married since ______ years.
• Marriage is consanguineous / non-consanguineous.
5. PRESENT OBSTETRIC HISTORY
First Trimester
Obstetrics History Taking Page 1
, • Pregnancy was confirmed by urine pregnancy test (UPT) at ______ after ______ days from the last
menstrual period.
• Dating scan done at ______ weeks.
• History of hyperemesis gravidarum / pregnancy-induced complications as documented in the
source notes.
• History of exanthematous fever, radiation exposure or drug intake.
• History of bleeding per vaginum (PV), acute abdominal pain and leucorrhoea (fungal infection) —
present / absent as applicable.
• First dose of tetanus-diphtheria (Td) and folic acid taken.
Second Trimester
• NT scan done and found to be normal.
• Quickening felt at ______ months (approximately 14–16 weeks).
• Anomaly scan done and found to be normal (approximately 18–20 weeks).
• OGCT done at 18–20 weeks, 28–32 weeks and 36–40 weeks as recorded in the source notes.
• History of gestational diabetes mellitus (GDM), hypertension, bleeding / spotting per vaginum.
• History of iron-sucrose injection, if any.
• Second dose of Td taken.
Third Trimester
• Able to perceive fetal movements.
• Growth scan taken and found appropriate for gestational age (around 30 weeks in the source
notes).
• History of hypothyroidism, GDM, hypertension, bleeding / spotting per vaginum.
• History of iron-sucrose injection.
6. PREVIOUS OBSTETRIC HISTORY
For each previous pregnancy, document antenatal care and antenatal complications; intrapartum
history and complications; postpartum history and complications; and postnatal history.
Pregnancy
Year / age Gestation Mode of delivery Birth weight Baby / NICU / outcome
1 ________ Term / Preterm ________ ________ ________
2 ________ Term / Preterm ________ ________ ________
3 ________ Term / Preterm ________ ________ ________
• For each child: term / preterm; mode of delivery (including indication such as CS, if applicable);
place/date of delivery; baby cried after birth; breastfed within ______ hours; NICU admission / no
admission; urine and meconium passed at ______.
Obstetrics History Taking Page 2
Typed & enriched version
This document is a clean, typed presentation of the uploaded handwritten obstetric history-taking notes. Blank
fields and alternative options have been retained rather than inventing patient-specific details.
1. IDENTIFICATION DATA
Patient Mrs. ______________________________
Age ________ years
Occupation ______________________________
Husband's name / occupationMr. __________________ / __________________
Obstetric status Gravida ______ Para ______ Living ______ Abortions ______
Residence ______________________________
Socio-economic status ______________________________
Booking / immunization status
Booked / Immunized / Both / __________________
Date of presentation ______________________________
Chief complaint(s) ____________________________________________
2. OBSTETRIC DATING
LMP: ____________________ EDD: ____________________ GA: ____________________
Obstetric code: ______________________________________________
3. HISTORY OF PRESENTING OBSTETRIC COMPLAINTS
Patient presents with ______ months of amenorrhoea with complaints of
______________________________.
For the presenting complaint: onset, duration, severity, relieving factors, aggravating factors,
associated symptoms, and medications used are to be elicited.
Menstrual history: Menarche at ______ years. Cycles were regular / irregular, approximately ______
days, with flow lasting ______ days. About ______ pads/day were used; pads were partially / fully
soaked. Associated with / without lower abdominal pain, backache and clots. LMP:
____________________.
4. MARITAL HISTORY
• Married at the age of ______ years.
• Married since ______ years.
• Marriage is consanguineous / non-consanguineous.
5. PRESENT OBSTETRIC HISTORY
First Trimester
Obstetrics History Taking Page 1
, • Pregnancy was confirmed by urine pregnancy test (UPT) at ______ after ______ days from the last
menstrual period.
• Dating scan done at ______ weeks.
• History of hyperemesis gravidarum / pregnancy-induced complications as documented in the
source notes.
• History of exanthematous fever, radiation exposure or drug intake.
• History of bleeding per vaginum (PV), acute abdominal pain and leucorrhoea (fungal infection) —
present / absent as applicable.
• First dose of tetanus-diphtheria (Td) and folic acid taken.
Second Trimester
• NT scan done and found to be normal.
• Quickening felt at ______ months (approximately 14–16 weeks).
• Anomaly scan done and found to be normal (approximately 18–20 weeks).
• OGCT done at 18–20 weeks, 28–32 weeks and 36–40 weeks as recorded in the source notes.
• History of gestational diabetes mellitus (GDM), hypertension, bleeding / spotting per vaginum.
• History of iron-sucrose injection, if any.
• Second dose of Td taken.
Third Trimester
• Able to perceive fetal movements.
• Growth scan taken and found appropriate for gestational age (around 30 weeks in the source
notes).
• History of hypothyroidism, GDM, hypertension, bleeding / spotting per vaginum.
• History of iron-sucrose injection.
6. PREVIOUS OBSTETRIC HISTORY
For each previous pregnancy, document antenatal care and antenatal complications; intrapartum
history and complications; postpartum history and complications; and postnatal history.
Pregnancy
Year / age Gestation Mode of delivery Birth weight Baby / NICU / outcome
1 ________ Term / Preterm ________ ________ ________
2 ________ Term / Preterm ________ ________ ________
3 ________ Term / Preterm ________ ________ ________
• For each child: term / preterm; mode of delivery (including indication such as CS, if applicable);
place/date of delivery; baby cried after birth; breastfed within ______ hours; NICU admission / no
admission; urine and meconium passed at ______.
Obstetrics History Taking Page 2
