Obstetrics and Gynaecology History Taking Template

OBSTETRICS AND GYNAECOLOGY HISTORY TAKING 1.  Introduction  Name: • Age: • • Gravida: Para: • Job: • Ethni gro!": • POA: • Previo!# Ob#tetri $i#tor%: • • &h% re''ered(admitted: A!te #%m"tom)#*: •

1+ .+ -+ ;+ <+ =+ ?+ 2+ @+

Intro trod!tion ,en# ,en#tr tr!a !a// $i#t $i#tor or% % $i#to i#tor% r% o' Pre# Pre#en entt Pregnan% Pa#t a#t Ob# Ob#te tetr tri i $i#tor% Pa# Pa#t G%na G%naee $i#to i#tor% r% Pa#t a#t ,edi ,edia a// > S!rgia/ $i#tor% 7ami/% i/% $i#to i#tor% r% Soia ia/ $i#to i#tor% r% S!mmar%

E+g+ P!an Siti ,ariam i# a -. %ear o/d o/d ,a/a% #hoo/ teaher 0 Gravida -+Para 10 Abortion Abortion 10 at -2 3ee4# ge#tation0 admitted admitted 'or an E/etive Cae#arean Setion 'or a Breeh Pre#entation+  55555555555555555555555555555555555555555555555555555555555   55555555555555555555555555555555555555555555555555555555555   55555555555555555555555555555555555555555555555555555555555   5555555555555555555555555555555555555555555555555555555555   56  55555555555555555555555555555555555555555555555555555555555  •

2. Menstrual History • Age o' ,enarhe: Age o' ,eno"a!#e)i' a""ro"riate*: • Period: • Reg!/ar(Irreg!/ar  7re8!en%)$o3 o'ten do %o!r "eriod# ome9* D!ration)$o3 /ong do the% /a#t9*  No o' "ad#(tam"on# !#ed "er da% 7/ooding Pa##age o' /ot# D%#menorrhoea: • • ,enorrhagia: B/eeding)Intermen#tr!a/0 Po#toita/0 Po#tmeno"a!#a/*: • 7ir#t Da% O' the La#t  Normal ,en#tr!a/ "eriod)LN,P*: • E"eted Date O' De/iver%)EDD*: •      

•

Correted(Revi#ed EDD:

-+ History of resent re!nancy P/anned(n"/anned: • &hen Con'irmed9 $o39 &here9 PT or (S9 • Prob/em# in 7ir#t Trime#ter)B/eeding0 vomiting*: • • Boo4ing)1#t antenata/ vi#it* o &here9 o Ro!ntine Inve#tigation#: &t:555555 $t:55555 BP:555555  !i4ening)1#t 'eta/ movement*: • ,GTT)done in .nd trime#ter*: • Antenata/ he4!" • o $o3 o'ten9 o  N!mber9 Co/o!r oding)3hite0 green0 %e//o30 red*: • B/ood te#t# • o $b: o B/ood Gro!": o Rh: o In'etive Sreening)$I(DRL($e"atiti#*: • rine eamination)'or a/b!min > #!gar*: • Prob/em# in .nd trime#ter)e+g+: anaemia*: Prob/em# in -rd trime#ter),edia/(Ob#tetri*: •

". ast O#stetric History Gravida: • Para: • Abortion#(eto"i#(mo/ar: • • Eah "regnan%: o Date: o POA: o T%"e o' De/iver%: o &here: •

•

Bab% Detai/#: o &t: o Se: o Condition at birth)Did bab% r% immediate/% a'ter birth9* Com"/iation# in 1#t0 .nd0 -rd trime#ter#:

• • • • • •

An% "roed!re# done9)IC(LR($D& et*: Brea#t'eeding: Imm!ni#ation#: Contrae"tion:+ Abortion#+T%"eD>C++Con'irmed or not+$PE: Eto"i#(,o/ar+Detai/#:

$. ast Gynaecolo!ical History An% "revio!# g%nae hi#tor%9 • o e+g+ 'ibroid#0 endometrio#i#0 PID An% o"eration# done9 )Detai/#(om"/iation#*: • Pa" #mear)$o3 o'ten9 Re#!/t#*: • %. ast Medical and Sur!ical History An% media/ hi#tor%9 • o Di#ea#e: o Admi##ion#: o Treatment given: An% hroni i//ne##9)e+g+ diabete#0 h%"erten#ion* • o Long term treatment: An% #!rgia/ o"eration#9 Detai/#: • ,A an% "rob/em#9 &hat in!rie# #he had9 )"e/vi# in!r%9*: • Di#ea#e# 3hih e''et "regnan%: • • Pregnan% 3or#en# the di#ea#eeg $eart di#ea#e#: &. 'amily History • Parent#0 detai/#: Chroni di#ea#e# in 'ami/%: • Sib/ing#: • o  N!mber o' #ib/ing#: o Gir/#++di#ea#e# )eg 'ibroid#*: ,!/ti"/e "regnan%: • 7eta/ abnorma/itie#: • ,a/ignan%: • (. Social History PatientF# 3or4detai/#++month/% inome: • • $!#band# 3or4++detai/#++month/% inome: • Tota/ 'ami/% month/% inome:

• • • • • •

$!#bandF# media/ hi#tor%++i' an%: Smo4ing: A/oho/: I//iit Dr!g#: Aommodation detai/#)E/ertriit%(&ater(Sanitation*: Diet $i#tor%

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