Unique id:
Institute name:
Ip op number:
First name:
Last name:
Age:
Weight:
Height:
Bmi:
Address street:
Address pin code:
Address state:
Address country:
Contact number:
Email:
Education: --------- Profession or Honours Graduate or Postgraduate Intermediate or post high school diploma High school certificate Middle school certificate Primary school certificate Illiterate
Occupational status: --------- Legislators, senior officials, and managers Professionals Technicians and associate professionals Clerks Service and sales workers Skilled agricultural and fishery workers Craft and related trades workers Plant and machine operators and assemblers Elementary occupations Unknown
Income: --------- Less than 10,000 10,000 to 19,999 20,000 to 29,999 30,000 to 39,999 40,000 to 49,999 50,000 or more
Gestational age: --------- Early term (37–38 weeks) Full term (39–40 weeks) Late term (41 weeks) Post term (42 weeks or more)
Fever above 38 5: --------- Yes No
Fever more than 24 hours: --------- Yes No
Headache: --------- Yes No
Blurring of vision: --------- Yes No
Generalized swelling: --------- Yes No
Puffiness of face: --------- Yes No
Palpitations: --------- Yes No
Easy fatiguability: --------- Yes No
Breathlessness at rest: --------- Yes No
Pain in abdomen: --------- Yes No
Vaginal bleeding: --------- Yes No
Watery discharge: --------- Yes No
Reduced foetal movements: --------- Yes No
Current or past systemic illness: --------- Yes No
Past history of illness: --------- Yes No
Twin or multiple pregnancy: --------- Yes No
Malpresentation: --------- Yes No
Previous lsces: --------- Yes No
History of stillbirth: --------- Yes No
Abortion: --------- Yes No
Congenital malformation: --------- Yes No
Obstructed labour: --------- Yes No
Premature birth: --------- Yes No
Prior thyroid dysfunction: --------- Yes No
Goitre: --------- Yes No
Mental retardation in family: --------- Yes No
Mental retardation in previous birth: --------- Yes No
Recurrent miscarriage: --------- Yes No
Preterm delivery: --------- Yes No
Intrauterine death: --------- Yes No
Abruptio placentae: --------- Yes No
History of infertility: --------- Yes No
Weight gain:
Current or past sti: --------- Yes No
More than one sexual partner: --------- Yes No
Sex workers: --------- Yes No
Injecting drug users: --------- Yes No
Syphilis: --------- Yes No
Hiv positive: --------- Yes No
Previous caesarean sections: --------- Yes No
Intrauterine growth retardation: --------- Yes No
Post partum hemorrhage: --------- Yes No
Pulse per minute:
Blood pressure systolic:
Blood pressure diastolic:
Temperature:
Fundus height: --------- Below expected Within expected Above expected
Pregnancy duration: --------- Preterm Term Post-term
Haemoglobin:
Blood group: --------- Positive Negative
Rh factor: --------- Positive Negative
T3:
T4:
Tsh:
Blood sugar fasting:
Blood sugar random:
Blood sugar post prandial:
Proteinuria: --------- Negative Trace 1+ 2+ 3+ 4+
Plasma glucose value:
Placenta prev: --------- Normal Low lying Placenta previa
Low lying placenta: --------- Normal Low lying Placenta previa
