Assessment of the Pregnant Female

Name: _____________________________________ Date: ________________

Age: _________ Marital Status/Significant Other: __________________________
Gravida: __________ Para: __________ AB: ____________LMP: ________ EDC: ________

Review of history of the pregnant female:

_____________________________________________________________________________
YES/NO If YES, provide details:
_____________________________________________________________________________

Past Medical History

Acute medical conditions
Chronic medical conditions
Gynecological conditions
Gynecological surgery
Infertility
Genetic conditions/concerns ___________________________________________
Domestic abuse/violence
STD history
Nutrition history
Anemia
Cancer
Breast health (BSE)
Mental health
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
____________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________

Past Obstetrical History

Number of pregnancies ___________________________________________
Number of term pregnancies ___________________________________________
Number of live births ___________________________________________
Abortions (type) ___________________________________________
Deceased children (cause) ___________________________________________
Obstetrical complications ____________________________________________
Prenatal ____________________________________________________
Intrapartal ___________________________________________________
Postpartum __________________________________________________

Assessment of the Pregnant Female Page 1 of 4

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Current Health Status
Acute medical conditions _____________________________________________
Chronic medical conditions _____________________________________________
Mental health _____________________________________________
Allergies _____________________________________________
Medications ____________________________________________
_____________________________________________
Infertility treatment ____________________________________________
Gynecological conditions ____________________________________________
STD ____________________________________________
Immunization status (hepB, hepA, influenza, tetanus) _______________________
__________________________________________________________________
Sexual activity (number of partners) _____________________________________
Smoking ____________________________________________
Substance use ____________________________________________
Abuse/violence ____________________________________________
Nutrition ____________________________________________
Nausea/vomiting ____________________________________________
Vaginal bleeding ____________________________________________
Urinary symptoms _____________________________________________

Family History
Medical history: ________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Genetic implications ____________________________________________________
___________________________________________________________________

Social History
Support: _____________________________________________________________
Employment: _________________________________________________________
Education: ___________________________________________________________
Fitness activity: ______________________________________________________
Living arrangements: __________________________________________________
_____________________________________________________________________
Violence: _____________________________________________________________

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 Review of history related to the current visit:
Focused symptom analysis of current problem:

Reason for visit: ________________________________________________________

_______________________________________________________________________
_______________________________________________________________________
Character: _____________________________________________________________
Onset: ________________________________________________________________
Duration: ______________________________________________________________
Location: ______________________________________________________________
Severity: ______________________________________________________________
Associated problems: ___________________________________________________
Efforts to treat: _________________________________________________________

Physical Assessment

Vital Signs:
BP: __________ Pulse: ________ Temperature: ________ Respirations: _________
Height: __________ Weight: __________ BMI: ___________
Pregnancy Test: _____________________________
Urine (Note protein, RBCs): _____________________
Hct/Hgb: ____________________________________
Blood Type and Rh: __________________________
FHT (location): ______________________________
Skin: _________________________________________________________________
HEENT: _______________________________________________________________
Neck and thyroid: _______________________________________________________
Lungs: ________________________________________________________________
Breasts: _______________________________________________________________
Heart/cardiovascular: ____________________________________________________
_______________________________________________________________________
Gastrointestinal: _______________________________________________________
Neurological (Note reflexes): ______________________________________________
_______________________________________________________________________
Musculoskeletal: _______________________________________________________
Extremities (Note edema): ________________________________________________
Abdomen (size, shape, fundal height, fetal heart tones, fetal movement): ____________
_______________________________________________________________________

Assessment of the Pregnant Female Page 3 of 4

© 2007, Pearson Education, Inc.
 Pelvic Exam
External genitalia: ________________________________________________
Pelvic measurements (if available): __________________________________
Vagina: _________________________________________________________
Cervix: __________________________________________________________
Rectal exam: __________________________________________________________

Analysis:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Assessment of the Pregnant Female Page 4 of 4

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