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OBGYN History Form
- 1. Page 1 of3 OBGYN History Report DEMOGRAPHICAL DATA Name: ……………………………………………. Age: ……………………………………………… Marital Status: ……………………………………. Gravidity/Parity/Abortions: ……………………… Date/Time of Admission: ………………………… Address: ………….………………………………. Blood Group: ……………………………………. Occupation: ……………………………………… If pregnant: LMP: ………….….………....…...…. EDD: ………..….……………...…. GA: ……………………...…. PRESENT COMPLAINT ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- HISTORY OF THE PRESENTING COMPLAINT ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- PAST M/S HISTORY ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------
- 2. Page 2 of3 HISTORY OF THE CURRENT PREGNANCY History of antenatal care, complications, labs, investigations, images, supplements, mode of delivery, … etc ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- PAST PREGNANCY HISTORY Preg # Year Sex GA Delivery Mode Weight Complications MENSTRUAL/GYNAECOLOGICAL HISTORY ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------
- 3. Page 3 of3 DRUG HISTORY ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ALLERGIES ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- FAMILY HISTORY ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- SOCIAL HISTORY AND LIFESTYLE ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- NOTES ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- This history form was developed by MohmmadRjab Seder