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Name: ________________________________________________ Where & When: ________________________________________ Where: Health Center/Private OB/OPD/Other: ________________
Age: ____ Birthday: __________ Birthplace: __________________ Medication: ___________________________________________ Associated signs and symptoms:
Sex: ____ Nationality: _______________ Religion: _____________ Drug, Dosage: __________________________________________ Nausea: ______ Vomiting: _______ Urinary Disturbances: ______
Classification: __________________________________________ Duration of treatment: ___________________________________ Fatigue: ______ Breast tenderness & tingling sensation: ________
Address:_______________________________________________ Prescribed or Self Medication: _______ _____________________ Chloasma: ______ Melasma: _________ Weight Gain: _________
Occupation: ___________________________________________ Effect of Drug: _________________________________________ Prepregnant weight: _____ Other Signs & Symptoms: _________
Date of Admission/ Consultation: __________ # Consultation: ___ Remedies (done at home): ________________________________ Ultrasound: ____________________________________________
Informant: __________________________ Reliability: ________% Change of Position: ______________ Diet: ___________________ Urinalysis: _____________________________________________
CHIEF COMPLAINT: Herbal Medicine: ________________ Massage: _______________ Other Test: ____________________________________________
Onset: ________________________________________________ **Prenatal, Birth, & Neonatal: Included only in patients <2 years Quickening: ____________________________________________
old or if related to the illness of children > 2 years old)
Location: ______________________________________________ Alcohol: _______________________________________________
A. GESTATIONAL HISTORY (PRENATAL HISTORY)
Radiation: _____________________________________________ Cigarette Smoke: _______________________________________
Age of mother (during pregnancy):_________________________
Duration: ______________________________________________ Toxic Chemicals: ________________________________________
OB score: G: _____ P: ______ (T:______ P:_____ A:_____ L:_____)
Timing/Frequency: ______________________________________ Accident: ______________________________________________
Pregnancy: Planned/Unplanned and Wanted/Unwanted
Quality: _______________________________________________ Trauma: ______________________________________________
Pregnancy: With/Without Attempt of Abortion
Quantity: ______________________________________________ Travel: ________________________________________________
Health: ______________________________________________
Severity: ___________________________________ (Rate 1 10) B. BIRTH (NATAL HISTORY)
Nutrition: _____________________________________________
Precipitating Factor:_____________________________________ AOG: Term/Preterm/Postmature: __________________________
Infections: _____________________________________________
Hours of Labor: _________________________________________
Manner of Delivery: NSVD/LCCS: ___________________________ Dilution and Amount/day: ________________________________ Food likes: _____________________________________________
Place of Delivery: _______________________________________ Bottle feeding or Cup feeding: _____________________________ Food dislikes: __________________________________________
Person who attended Delivery: ____________________________ Complimentary Foods: ___________________________________ Feeding difficulties: _____________________________________
TOTAL
MIDDLE CHILDHOOD (6-11 YEARS)
Assess if basic food group are eaten daily: ___________________ Severity: ______________________________________________
Formula Milk Used: _____________________________________
Complications: _________________________________________ Disease/Age: ___________________________________________ Educational Attainment: _________________________________
Duration: ______________________________________________ IMMUNIZATION HISTORY & TUBERCULIN TEST Educational Attainment: _________________________________
Surgical Operation: ______________________________________ Father/Age: _______ Status: Alive:________, Deceased:________ Exposure to environmental pollutants: ______________________
Type: _________________________________________________ Mother/Age: _______Status: Alive: ________, Deceased: _______ Living arrangement (family/friends/relatives): ________________
Place: ________________________________________________ Mothers Condition: _____________________________________ Physical and social aspect of home: _________________________
Disease/Age: ___________________________________________ Siblings: #Brother: _______________ #Sister: ________________ # Storey: ____________________ # rooms: __________________
Complications: _________________________________________ Siblings/Health status: ___________________________________ Window type: ________________ Ventilation: _______________
Allergy/Eczema/Food or Drug Sensitivity/Other: ______________ Position in the family: ____________________________________ Location of residence: ___________________________________
Severity: ______________________________________________ HPN: _____________ Diabetes: ___________ Arthritis: ________ Sources of drinking water: ________________________________
Complications: _________________________________________ PTB: _____________ CVD: _______________ Asthma: _________ Source of domestic water: ________________________________
Asthma: ______________________________________________ Allergies: _________ Cancer: ____________ Psychiatric: _______ Sanitation (inside and outside): ____________________________
Severity: ______________________________________________ Peptic ulcer: _________ BPH: ____________ Twinning: ________ Type of toilets disposal: __________________________________
8. GASTROINTESTINAL: ( ) anorexia, ( )
nausea/retching, ( ) vomiting, ( ) dysphagia, ( )
hematemesis, ( )indigestion, ( ) melena, ( )
hematochezia, ( )heartburn, ( ) abdominal pain, (
) hernia, ( ) hemorrhoids, ( ) use of laxatives