Republic of the Philippines

Provincial Government of Palawan

NARRA MUNICIPAL HOSPITAL
Antipuluan, Narra, Palawan

PRENATAL CHECKLIST
PATIENT’S INFORMATION
NAME: ________________________________________________________ AGE: ______ DATE
LABORATORY RESULT
ADDRESS: _________________________________________________________________ DONE
CBC WITH
CONTACT PERSON IN CASE OF EMERGENCY:________________________________ PC
DATE OF FIRST VISIT (outside NMH): __________________ BT
DATE OF FIRST VISIT AT NMH: ________________________ Smoker: _______________
OGTT
LMP: _____________ ___________ stick/day
EDD: _____________ ___________ No. of Years VDRL
AOG: ____________ Alcoholic Drinker:
HBSAG
NUMBER OF PREGNANCY: ________________ _______________________
HIV
FAMILY HISTORY PAST MEDICAL HISTORY URINALYSIS
OTHERS:
( ) Unremarkable ( ) Unremarkable
( ) Hypertension ( ) Hypertension
( ) Diabetes Mellitus ( ) Diabetes Mellitus
( ) PTB ( ) PTB TETANUS VACCINATION
( ) Bronchial Asthma ( ) Bronchial Asthma 1ST DOSE
( ) Cancer ( ) Cancer
( ) Goiter ( ) Goiter 2ND DOSE

3RD DOSE
HISTORY OF PREVIOUS PREGNANCY
4TH DOSE
(YES: Y NO: N)
Date of Delivery 5TH DOSE
TYPE OF DELIVERY ULTRASOUND
NORMAL DELIVERY FIRST
CAESAREAN DELIVERY C/S SECOND

Reason of C/S THIRD

BIRTH OUTCOME NOTES:
ALIVE
MISCARRIAGE

STILLBIRTH

NUMBER OF CHILD/CHILDREN DELIVERED

SINGLE

MULTIPLE BIRTH: NO: _____

PREGNANCY-RELATED CONDITIONS/COMPLICATION
PREGNANCY INDUCED HPN

PREECLAMPSIA/ECLAMPSIA
BLEEDING DURING PREGNANCY
OR AFTER DELIVERY
OTHERS:

ADVISED:

HIGH RISK PREGNANCY? YES/NO

RECOMMENDATION
 Republic of the Philippines
Provincial Government of Palawan
NARRA MUNICIPAL HOSPITAL
Antipuluan, Narra, Palawan