This document contains an antenatal assessment of a pregnant mother. It includes sections on the mother's personal history, medical history, obstetric history, physical examination, and antenatal investigations and medications. The physical examination section documents vital signs, general appearance, assessments of various body systems, and an obstetrical examination including fetal position, heart rate, and uterine measurements. The investigations section will track laboratory results. The medication section lists any drugs prescribed along with dosages and monitoring by nurses. Health education provided to the mother is also documented.

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