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Age of the mother: _______ OB Score: G P ( - - - ) Similar illness in the family: ___________________________________________
( ) PTB ( ) seizure
( ) smoker ( ) alcoholic beverage drinker ( ) illicit drug use: _______________
( ) bronchial asthma ( ) hypertension
Prenatal Check-up: total of ___________ PNCUs ( ) cancer ( ) diabetes mellitus
Start: _____________________ AOG Attended by: _________________________ ( ) heart disease ( ) kidney diseases
Last: ______________________ AOG Attended by: ________________________ Others: ____________________________________________________________
Prenatal Medications: ________________________________________________ SOCIAL AND ENVIRONMENTAL HISTORY
UTZ: _________ AOG: ______________ _________ AOG: ______________ House: ________ storey ( ) concrete ( ) wooden
Maternal Illnesses During Pregnancy: ____________________________________ Ventilation: ________________ Lighting: __________________
Labs done/Meds taken: _______________________________________________ No. of household members: _________
Date Sex AOG Manner Place Attendant Complications Drinking water: _______________________ ____ If tap, boiled? ( ) Yes ( ) No
G1 Garbage Disposal: _______________ _____ x/week Toilet: ________________
G2 ( ) History of travel: _______________________ _____ When? ______________
G3 ( ) Exposure to smoking ( ) Nearby Dumpsite ( ) Nearby factories
G4 ( ) Pets: _____________________ ____ Stay inside the house? ( ) Yes ( ) No
G5 !" $%&'() *+ $' ,- . /012
PSYCHOSOCIAL ASSESSMENT FOR ADOLESCENTS (HEADSSFIRST)
HOME. Space, privacy, frequent geographic moves, neighborhood.