This file contains each criteria of health assessment of antenatal mother.

1. ANTENATAL ASSESSMENT
I. Profile of Mother
Name of the Mother :
Age :
Hospital No :
Educational Status :
Occupation :
Religion :
Address :
Name of the Hospital :
Date of Admission :
Ward :
LMP :
EDD :
Obstetrical Score : G P L A
Weeks of gestation :
Chief complaints :
II. Socio-economic Status:
Type of Family : Nuclear / Joint / Extended
Bread Winner :
Total income of the family :
Type of House : Thatched / Tiled / Terraced
Ownership of House : Own / Rented
Electricity& Water Supply :
Drainage & Kitchen Garden :
Latrine & Refuse Disposal :
Ventilation :
Pet Animals :
III. Family History:
S.No Name of
the Family
members
Age Sex Educational
Status
Occupational
status
Relationship
with the
mother
Health
status
b) Family Medical History:
IV. Personal History:
(a) Personal Habits : Tobacco chewing, cigarette smoking, alcohol, coffee, cola, tea
(b) Diet
Vegetarian/Non Vegetarian :
Allergies to any food item :
Number of meals and snacks/day :
Likes & Dislikes of food :

2. (c) Sleep/Rest
Number of hours per day & night :
Wake times :
Difficulties in sleeping :
(d) Activities of daily living
Any difficulties experienced in the basic activities
(e) Elimination
Bowel habits - Number of times per day :
Bladder habits - Number of times during day and night :
(f) Menstrual History
1. Age at menarche :
2. Duration of cycle :
3. Amount of flow :
4. Regular/Irregular :
5. Any abnormalities :
(g) Marital History
consanguineous / Non consanguineous
Duration of marriage :
(h) Contraceptives :
(i)Drug History
Drug Allergies :
V. Past Medical History & Surgical history
VI. Present Medical History:
VII. Past Obstetrical History:
S.
No.
Month
& Year
Mother Baby
Compli
cation
during
pregna
ncy
Abortion/
Preterm /
Full term
Type of
Delivery
Complication
during
Puerperium
Sex Birth
Weight
Condition
at Birth
Health
Status

3. VIII. Present Obstetrical History:
 1st trimester: H/o Nausea, vomiting, pica, Anorexia, Constipation,
Exposure to drugs/ radiation / infection / Any Other
 2nd trimester: H/o heart burn, back ache, muscle cramps, Anemia, GDM, PIH, Any
Other
Quickening felt at:
Weight Gain : Normal / Abnormal - specify kgs-
 3rd
trimester : H/o heart burn, constipation, frequency of micturition, Any Other
Lightening : Yes / No
Fetal Movement: Normal / Excessive / Less / Not Felt
IX. Antenatal Attendance:
Date Wt
In
Kg
Urine B.P
mm
of
Hg
Weeks of
Gestation
Ht of
Fundus
in
weeks
Presentation F.H.R
per
minute
Treatment
& Remarks
Alb Sugar
X. Physical Examination:
GENERAL CONDITION:
Height : cms
Weight : kgs
BMI :
Gait :
Posture :
VITAL SIGNS:
Temperature :
Pulse :
Respiration :
BP :
GENERAL APPEARANCE:
Body Built :
Health Status :
Activity :

4. MENTAL STATUS
Orientation :
Facial expression : Normal / Anxious / Depressed
Any Other :
HEAD TO FOOT ASSESSMENT
HEAD:
Hair : Clean Colour Texture
Scalp : Clean / Dandruff
Any Other problems :
FACE:
Pallor :
Oedema :
Chloasma :
Any Other :
EYES:
Vision :
Conjuntiva :
Sclera :
Eye lids :
Eye Ball :
PeriorbitalOedema :
EARS:
Hearing :
Any Other :
NOSE:
Septal Deviation :
Any other :
MOUTH:
Lips :
Tongue :
Teeth :
Gums :
Mucosa :
NECK:
Lymph Nodes :
Thyroid :
CHEST:
Movement :
Respiration :
Breath sound :
Heart beats :
Murmur :
EXTREMITIES
Upper Lower
Edema : Edema :
Nails : Varicose Veins :
ROM : ROM :

5. BACK:
Deformity :
Any other :
XI. Obstetrical Examination: Antenatal
BREAST:
Inspection:
Size :
Shape :
Nipple :
Areola Primary :
Secondary :
Montgomery’s Tubercles :
Skin colour :
Palpation:
Nodules / Lumps :
Colostrums :
ABDOMEN:
Inspection :
Shape :
Size :
Skin changes :
Umbilicus :
Muscle tone :
Contour :
Flank :
External Fetal movement :
Previous scar :
Palpation :
Measurement :
Height of the Fundus: cms Finger Breadth Method : wks
Abdominal girth : cms
Fundal Palpation:
Lateral: Right
Left
Pelvic Palpation: Grip I
Grip II
Auscultation :

6. PERINEUM:
Hygiene :
Discharge :
Bleedings :
Oedema :
Pruritis :
Infection :
FINDINGS
Lie :
Presentation :
Position :
Attitude :
Engagement :
FHR :
XII. Investigations:
DATE INVESTIGATIONS PATIENTS VALUE NORMAL VALUE REMARKS
OTHERS:

7. XIII. Medication
Date Name of the
drug & dose
Route &
frequency
Action Side effects Nurses
responsibility
XIV. Antenatal Advices / Health Education On:
SIGNATURE OF THE STAFF