OB-GYN HISTORY and PE GUIDE

Identifying Data
Name: ____________________________ Age: _______ Marital Status: ___________
Gravidity and Parity (GTPAL): _____________________ Religion: _______________
Occupation: _____________________________ Address: ______________________
Date and Time of Hx Taking: ________________ Reliability (0-100%): _____________

Chief Complaint: _______________________________________________________________

History of Present Illness: (*Pain: PQRST)

If for routine check prenatal care, should state:

LMP: __________________________________________________________
PMP: __________________________________________________________
AOG: __________________________________________________________
EDC: ___________________________________________________________
(+/-) Good Fetal Movement: _______________________________________
Danger Signs of pregnancy if present/absent: __________________________
(Headache, Blurring of vision, Prolonged Vomiting, Fever,
Nondependent edema, Epigastric/RUQ pain, Dec fetal movement,
Dysuria, Bloody vaginal delivery, Watery vaginal delivery)

Antenatal History
Date of confirmation of pregnancy (thru test, ultrasound): _______________________
Antenatal/Prenatal Care history
First Trimester Second Third
Date of consult:
Place of Consult
With whom:
Diagnostic Tests
Requested:
Illness/treatment
during AP care:

Immunization: ________________________________________________

Past Medical History (Illnesses (include present medications), Surgery (procedure, date, place,
complications), Allergies, History of Blood transfusion)
 OB-GYN HISTORY and PE GUIDE

Family History
 HPN  Allergies
 DM  Hematologic Diseases
 Thyroid Disease  Heart Disease
 Asthma  Malignancies
Others: __________________________________________________________

Personal History and Social History: (smoking, alcohol intake, illicit drug use, educational
attainment, Lifestyle/home safety if applicable)

OB HISTORY
GRAVIDITY YEAR MANNER OF PLACE OF BIRTH FETAL OUTCOME COMPLICATIONS
DELIVERY DELIVERY ATTENDANT (WEIGHT/SEX)
(NSD/CS/VBAC) if
CS write indication

Menstrual History
Menarche: ____________________
Interval: _____________________
Duration: _____________________
Amount: ______________________
Symptoms: ____________________________________________________
LMP (if not stated in the HPI)
PMP
 OB-GYN HISTORY and PE GUIDE

Sexual History
Coitarche: ___________________________
# of sexual partners: _________________
Presence or absence of symptoms: ______________________________________
(dyspareunia, post-coital bleeding, etc.)
History of sexually transmitted infection: (include treatment/vaccination)
__________________________________________________________

Gynecologic History
Pap smear: ________________________________________
Use of Contraception: _______________________________
History of immunization: ____________________________

Review of Systems (all other symptoms unrelated to cc and HPI)

A. General Data:
Wt loss Fatigue Decreased/increased appetite weakness
Fever Clothing tighter or looser
B. Skin:
Rash Lumps Sores Itching Changes in hair/nails
Changes in size of color of moles
C. Head:
Headache Dizziness Lightheadedness Head injury
D. Eyes:
Blurring Vision Redness Pain Glasses / Lens
Excessive tearing Spots Flashing Lights Tunneling of vision
E. Ears:
Tinnitus Vertigo Infection Discharge Itching
Decreased Hearing Hearing Aid
F. Nose/Sinuses:
Itching Nosebleeds Frequent colds Nasal Stuffiness
Discharge Sinus trouble
G. Throat:
Bleeding gums Sore throat Dry mouth Hoarseness
Dentures
H. Neck
Lumps Goiter Pain Stiffness Swollen glands
I. Breast:
Lumps Pain/Discomfort Nipple discharge Self-exam practices
J. Cardiovascular:
Chest pain/discomfort Palpitation Dyspnea Orthopnea Edema
K. Respiratory:
Cough Sputum Hemoptysis Hemoptysis Dyspnea
L. Abdominal:
 OB-GYN HISTORY and PE GUIDE

Dysphagia Heartburn Vomiting prolonged Nausea Bowel habits

Rectal bleeding Black tarry stools Abdominal pain Diarrhea
Constipation Dyspepsia
Pregnancy: Quickening Abdominal cramping
Fetal movement
M. Genitourinary:
Urinary frequency Polyuria Nocturia Dysuria Hematuria
Incontinence
N. Peripheral vascular:
Leg cramps Varicose veins Swelling Tenderness
O. Genital:
Pre-pregnancy: Dysmenorrhea Bleeding bet periods or after intercourse
Pre-menstrual tension Discharge Itching Sores
Lumps
Pregnancy: Vaginal bleeding Discharge Pain
P. Musculoskeletal:
Bone/muscle/joint pain Arthritis Gout Backache
Limitation of motion Swelling Swelling Weakness
Neck pain
Q. Nervous:
Attention Vertigo Seizure Tingling sensation Paresthesia
Numbness Neck pain Tremors
R. Hematopoietic:
Easy fatigability Easy bruising
S. Psychiatric:
Depression Nervousness Suicide Attempt Mood

Physical Exam:
A. General Survey:
B. Vitals
a. BP:
b. CR:
c. RR:
d. Temp:
e. Weight:
f. Height
C. Skin:

D. HEENT

E. Neck

F. Breast
 OB-GYN HISTORY and PE GUIDE

G. Respiratory

H. Cardiovascular

I. Abdominal
a. Inspection
b. Leopold’s Maneuver
i. LM1:
ii. LM2:
iii. LM3:
iv. LM4:
c. Fundic Height:
d. Fetal Heart tones (bpm, location, RLQ,LLQ,etc.)

e. Extremities(esp. presence of edema)

f. Neurologic exam (if applicable)