NAME

SS#

:
:

SOCIAL SECURITY SYSTEM

Cauayan City
MEDICAL BENEFITS SECTION
_____________________
_____________________
DATE:

__________________

COMPLETE OBSTETRICAL HISTORY

(To be filled up by attending OB-Gynecologist)

A.OBSTETRICAL SCORE :

_______________________________

B.DETAILED OB HISTORY (Complete data below using this format)

G1

____________________

_____________________________

Type of Delivery
G2

= _____________________

_____________________________

Type of Delivery
G3

= _____________________

_____________________________

Type of Delivery
G4

= ______________________

_____________________________

Type of Delivery
C.OTHER REMARKS ( If any)
_________________________________________

Printed Name and Signature

PRC#