Anc Assessment
Anc Assessment
Anc Assessment
●PERSONAL PROFILE
Name:-
Age:-
Sex:-
Father Name:-
Mother Name:-
Grade/ Class:-
Completed by:-
Date of Assessment:-
A) Sociodemographic And Personal Information: -
▪Name:-
▪Age :-
▪Address:-
▪ Mobile no :-
▪Per Capital:-
▪Religion:-
▪Mother tongue:-
▪Dietary habits:-
▫Does the mother have PICA.
B) Medical History:-
▪Ask for any major illness. E.g. Allergies, jaundice, malaria, STD/RIT,
diabetes, hypertension, hypo/hyperthyroidism, tuberculosis, anemia, worm
inflectation, Rubella, etc. in the post or during pregnancy.
▪Ask for any blood transfusion received reason for transfusion and donor.
D) Family History:-
▪Ask for any illness in the family like diabetes, hypertension, etc.
▪Ask for any birth of twins/ multiple pregnancies in any family member.
F) Obstetrical History:-
▪After delivery mother & child care-
▪Enquire for the living children & their current health status as per the table
below-
▪ Status of Baby:-
POG-Period of a gestation-
G) Family Planning-
▪Have you adopted a family planning method?
▪Rh- factor- +,-, antigen antibody of the mother & her husband
▪HIV status of the mother & her husband human Immunodeficiency disease.
▪Hb level on
▪Blood sugar