ANTENATAL ASSESSMENT CHART

NAME

AGE

OCCUPATION

MARITAL STATUS

HEIGHT WEIGHT

BMI

ADDRESS

CHIEF COMPLAINTS OF THE PATIENT

PERIOD OF AMENOEEHOEA

NAUSEA, VOMITTING

MUSCULOSKELETAL PROBLEMS

CRAMPS

FREQUENCY OF MICTURATION

HEADACHE, EPIGASTRIC PAIN

SWELLING

MALAISE

PRESENT HISTORY

GPAL
HISTORY OF GASTROINTESTINAL SYSTEM

LOSS OF APPETITE

LOSS OF WEIGHT

HEART BURN

CONSTIPATION
HISTORY OF GENITOURINARY SYSTEM

INCONTINENCE

PROLAPSE

POLYURIA

BURNING MICTURITION

PAST HISTORY
ANY HISTORY OF T.B

SEIZURES

BLOOD PRESSURE

ANAEMIA

PREVIOUS HISTORY OF MUSCULOSKELETAL PROBLEMS

Rh INCOMPATIBILITY

OBSTERIC HISTORY
ST ND
S.NO NO OF MODE OF ANY 1 STAGE 2 STAGE BABY SEX BABY
DELIVERIES DELIVERY COMPLICATIONS OF OF WEIGHT
LABOUR LABOUR

MEDICAL HISTORY
CARDIAC PROBLEMS

HYPER OR HYPOTHYROIDISM

AUTO IMMUNE DISORDERS

BRONCHIAL ASTHMA
DRUG HISTORY

SURGICAL HISTORY
FAMILY HISTORY
TWINS

CONGENITAL DEFECTS

DIABETES MELLITUS

PERSONAL HISTORY
SMOKING, ALCOHOLISM

SLEEPING HABITS

SOCIO ECONOMIC HISTORY

OCCUPATION

FAMILY MEMBERS

ECONOMIC OUTCOME

LIFESTYLE

PSYCHOLOGICAL HISTORY
EMOTIONAL DISTURBANCES

ANXIETY/DEPRESSION

PAIN HISTORY
ONSET

DURATION

TYPE OF PAIN

LOCATION

AGGRAVATING FACTORS

RELIEVING FACTORS
NIGHT PAIN

IRRITABILITY LEVEL

VAS SCORE

ON OBSERVATION
GENERAL CONDITION- ECTOMORPH, ENDOMORPH,MESOMORPH

EDEMA

TROPHIC CHANGES

CHOLASMA

LINEA NIGRA

STRAIE GRAVIDUM

NAIL BED

CONJUCTIVA AND TONGUE

POSTURE

ANTERIOR VIEW

POSTERIOR VIEW

LATERAL VIEW

GAIT

ON PALPATION
TENDERNESS

TEMPERATURE VARIATION IN SKIN

SWELLING

ON EXAMINATION
1. VITAL SIGNS

BP

PULSE
 RESPIRATORY RATE

2. ABDOMINAL GIRTH
3. FUNDAL HEIGHT
4. LIE/PRESENTATION
5. RANGE OF MOTION
6. EDEMA ASSESSMENT

GIRTH

VOLUMETRIC

7. MANUAL MUSCLE TESTING

8. DTR
9. DIASTASIS RECTI ASSESSMENT
10. BREAST EXAMINATION

SIZE

NIPPLE

AREOLA

11. VARICOSE VEIN/DVT

12. INCONTINENCE ASSESSMENT
13. EXERCISE TOLERENCE TESTING

6 MINUTE WALK TEST

3 STEP TEST

14. SPECIAL TEST

15. FUNSTIONAL ASSESSMENT