NAME: BABY BOY/GIRL: _____________________________DATE OF BIRTH: _____________________________ TIME OF BIRTH: ____________________

LIVE BORN TERM/PRETERM, SINGLE, MALE/FEMALE DELIVERED VIA: ____________________________________________________________________

APGAR SCORE: ___________ BIRTHWEIGHT: ___________ APPROPRIATE/SMALL/LARGE FOR GESTATIONAL AGE: _____________________________

HOUR OF LIFE (IF LESS THAN 72 HOURS): ______________ DAY OF LIFE (IF MORE THAN 72 HOURS): _______________

CURRENT WEIGHT: ___________________ FROM: ______________

BALLARDS: 0, 6, 12TH HOUR OF LIFE (IF PRETERM) _____________________ 6TH AND 12TH (IF TERM) ________________

VITAL SIGNS (IN RANGE):

CR: __________________ RR: __________________ TEMP: ________________ O2 SAT: ___________________

TFI: _____________________ TFR: ____________________ URINE OUTPUT: ______________________ BOWEL MOVEMENT: __________________________

BIRTH HISTORY:

NEONATAL HISTORY:
MATERNAL HISTORY
FIRST TRIMESTER: The patient experienced the usual signs and symptoms of early pregnancy such as ___ cessation of menses, ___ urinary frequency, ___
breast tenderness, ___ easy fatigability, ___ nausea and vomiting on the _______ month of missed period (_____ Month _____Year). Self- pregnancy test was done
on the ___ month of missed period (_____ Month _____ Year) which revealed ( ) positive/ ( ) negative result. She consulted a private obstetrician where diagnostic
test such as complete blood count, urinalysis, hepatitis B antigen screening, VDRL/RPR, and 75g Oral glucose tolerance test which revealed normal results (if
abnormal, please indicate) __________________________________________________. Transvaginal ultrasound for pregnancy evaluation revealed a ( ) single/ ( )
multiple intrauterine pregnancy compatible to ___ weeks ___ days age of gestation (_____ Month _____ Year). She was given Multivitamins and folic acid 1 tablet
once a day which she took ( ) regularly/ ( ) irregularly. She denies any history of ( ) accidents, ( ) trauma, ( ) illness, or ( ) any exposure to radiation of toxic chemicals.
(If with history of any, please indicate diagnosis, duration, consultations done and/or management) ____________________________________________________

SECOND TRIMESTER: Quickening was felt on the ___ month of pregnancy (_____Month _____Year). She had a ( ) regular/ ( ) irregular intake of Multivitamins 1
tablet once daily, Ferrous Sulfate 1 tablet once a day, and Calcium 1 tablet twice a day. Complete blood count, urinalysis and fasting blood sugar were requested
revealing ( ) normal/ ( ) abnormal (if abnormal, please indicate results __________________________________________________________________________)
results. No medications were taken, but patient was advised increase fluid intake. Trans-abdominal ultrasound for age determinantion was done on the ___ month of
pregnancy revealing single, intrauterine pregnancy compatible to _____ weeks age of gestation (____Month _____Year). She denies any history of ( ) accidents, ( )
trauma, ( ) illness, or ( ) any exposure to radiation or toxic chemicals. (If with history of any, please indicate diagnosis, duration, consultations done and/or
management) ____________________________________________________________________

THIRD TRIMESTER: Subsequent prenatal check-ups were ( ) regular/ ( ) irregular as well as intake of Multivitamins 1 tablet once a day, Ferrous Sulfate 1 tablet
once a day and Calcium 1 tablet twice a day. (Please indicate the laboratory examinations done if there are any, as well as the results)
___________________________________________________________________________________________. She had no subjective complaints such as ( )
hypogastric pain, ( ) abnormal vaginal discharge, ( ) vaginal spotting, ( ) dysuria, ( ) fever, ( ) cough and colds. She denies any history of ( ) accidents, ( ) trauma, ( )
illness, or ( ) any exposure to radiation or toxic chemicals. (If with history of any, please indicate diagnosis, duration, consultations done and/or management)
_________________________________________________________________________________________________________ .
The present condition started _____ hours/days/weeks/months prior to admission, when the patient experienced ( ) crampy, ( ) intermittent, ( ) hypogastric pain
radiating to the ________________________ ( ) associated/ ( ) not associated with ( ) scanty, ( ) watery, ( ) bloody vaginal discharge. She sought consult at ( ) a
private physician/ ( ) our institution and was subsequently admitted.

OBSTETRICAL HISTORY
The patient is a ( ) primigravid/( ) multigravida with an obstetrical score of (Gravida_____ Para_____ (T___P___A___L___). The first pregnancy was delivered on
________________(Month, Year) to a ( ) term/ ( ) preterm, ( ) living/ ( ) still birth, ( ) boy/ ( ) girl with a birth weight of _____ kgs (___lbs), delivered via ( ) normal
spontaneous delivery/ ( ) forceps assisted vaginal delivery/ ( ) transverse LSCS due to ___________________________________________ (indication) at ( ) home/
( ) hospital/ ( ) lying-in clinic assisted by a ( ) midwife/ ( ) traditional birth attendant/ ( ) obstetrician. No fetomaternal complications were noted. He/She is now
_______ years old and is apparently healthy.
The second pregnancy was delivered (use same format as above) _________________________________________________________________________
PHYSICAL EXAMINATION:
HEENT: ( ) awake, ( ) active, with _____ cry and reflexes with the following VS (refer front page) ( ) open, soft, flat anterior and posterior fontanels, ( ) caput
succadeneum, ( ) cephalhematoma, ( ) pink palpebral conjunctivae, ( ) white sclera, ( ) bilateral well-formed pinna, ( ) patent ear canal, ( ) patent nostrils, intact lips
and palate.
NECK: ( ) supple, ( ) palpable lymph nodes, ( ) crepitations, ( ) limitation of movement
CHEST/LUNGS: ( ) symmetrical chest expansion
HEART: ( ) Adynamic precordium, ( ) normal rate ( ) regular rhythm, ( ) murmur
ABDOMEN: ( ) slightly globular, ( ) soft, ( ) normoactive bowel sounds, ( ) organomegaly, ( ) masses
SPINE: ( ) straight, ( ) midline, ( ) no tufts of hair
GENITALIA: ( ) normal-looking female/male external genitalia
EXTREMITIES: ( ) no gross deformities, ( ) full and equal pulses, ( ) CRT<2 seconds
REFLEXES: (+/-) palmar, (+/-) plantar, (+/-) Moro, (+/-) rooting, (+/-) Babinski

PLAN
DIET: _______________________________________________________

DIAGNOSTICS/LABORATORY RESULTS:

PRESENT IVF:
___________________________________________________________________________________________________________________________

DRUGS (with computed TD):

DRUG PREPARATION DOSE FREQUENCY REMARKS TD

DISPOSITION:
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________