DOONG MATERNITY CLINIC

PRENATAL RECORD Purok 29, Poblacion, Makilala, Cotabato

cjdoongbiochemistrysolutions@yahoo.com
639500951286

NAME : __________________________________ BIRTHDAY : __________________ AGE: _________ MARITAL STATUS :___________________

ADDRESS :_________________________________CONTACT NO: ________________PHILHEALTH: ________________ Menarch: ____________
BIRTH PLAN:
Ako ay papaanakin ni DOONG
LMP: _____________________________________ EDC:________________________OB SCORE: __________________ HEIGHT :_____________
MATERNITY CLINIC HEALTH CARE
Please assess the patient and check all the findings as you conduct your history taking specifically to the obstetrical and medical surgical risk factor. PROVIDER, ako ay manganganak sa
OBSTETRICAL RISK FACTOR
Multiple pregnancy Ovarian cyst Myoma uteri Placenta previa Abortion of three
DOONG MATERNITY CLINIC, ito ay
History of stillborn History of preeclampsia History of eclampsia Premature labor PHILHEALTH ACCREDITED na
MEDICAL SURGICAL RISK FACTOR paanakan, ako ay PhilHealth
Hypertension Heart disease Diabetes Thyroid disorder Obesity History of uterine member. Ang aking sasakyan
Asthma Epilepsy Renal disease Bleeding disorder Previous CS myomectomy
papunta sa paanakan ay
FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS FINDINGS LABORATORY RESULT: ___________.Kung may emergency
DATE HGB: at kailangan kong irefer sa hospital,
TIME ADMITTED Urine Analysis:
TIME DISCHARGE HBSAG ako ay magpaparefer
BLOOD PRESSURE ULTRASOUND RESULT: sa___________________________
RESPIRATORY RATE
CARDIAC RATE _ at ang aking Doctor ay si
TEMPERATURE _____________________________.
WEIGHT
AOG Ako ay ihahatid ng sasakyan ng
FHT DOONG MATERNITY CLINIC.
TT STATUS
FUNDIC HEIGHT
Observation
OBSERVATION NOTED: OBSERVATION NOTED: OBSERVATION NOTED:
___________________________________
Signature of Patient

VITAMIN SUPPLEMENTATION
______________________________
Name and Signature of the Patient