NUTRITIONAL ASSESSMENT PROFILE FOR PREGNANCY

Patient's Information: Date:

Name of Patient:
Age:
Address:
Estimated Date of Last Menstrual Period:
Estimated Date of Confinement/ Delivery:
Age of Gestation (Weeks): Term:
Number of Pregnancy/ Gravida & Parity: (1st, 2nd or 3rd)

Anthropometric:
Height:
Weight:
BMI:
Latest BP:

Biochemical:
CBC: Impression (High, Low or Normal)
White Blood Cells:
Red Blood Cells:
Hemoglobin (Hbg):
Hematocrit (Hct):

Platelet

Glucose (FBS):

Urinalysis
Urine Albumin:
Sugar:
Pus Cells:

Clinical
Ultrasound (UTZ):
Impression/ Result in Latest UTZ:

Physical Assessment:

Diet:
24 Hour Diet Recall
Breakfast Lunch Dinner Snacks

Fluids: Fluids: Fluids: Fluids:

(Yes/ No)
Special Diet: (Vegetarian, etc.) Caffeine:
Food Intolerance/ Allergies: Alcohol:
Vitamin/ Mineral Supplement: Smoking:

Activity Assessment: (Yes / No)

Exercise: Frequency:
Working Outside:
Work from Home:

Nurses Notes:

Date/ Time: Focus Data Intervention/ Action

Eg:
21-Oct-20 Low Hemoglobin; the 10 g/dL > The mother verbalize
> Educated the mother to eat understanding on the in
8:00 AM mother looks pale variety of meals, including food of iron in the diet
high in iron like dark green
leafy vegetables; also taking
the prescribed iron with folic
supplement

Pictures (for Documentation):

 If Yes: What is the frequency & Amount

Result

mother verbalizes
tanding on the increase
in the diet