Anc Assessment

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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 :-

▪How far are the various health care setting –


eg. Government Hospital, Primary health Centre, Subcenter or Private
clinic?

▪Number of family member:-


▪Types of family :-

▪Total income of family:-

▪Per Capital:-

▪Religion:-

▪Mother tongue:-

▪Husband Name & Age :-

▪Education of mother and her husband:-

▪Dietary habits:-
▫Does the mother have PICA.

▫Does the mother smokes take any drugs, alcohol, etc.

▫Any culture and Religion beliefs regarding pregnancy, delivery, new


born.

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.

▫When did it start?

▫Does the problem still persist?

▫Is any medicine being taken for the problem?


C) Surgical History:-
▪Ask for any surgery performed and subsequently verify the available record
and see for any surgical scar-

▪Ask for any blood transfusion received reason for transfusion and donor.

▪STD- Sexual Transmitted Disease.


▪PICA-Bad habits

▪RTI- Reproductive tract infection.

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.

▪Ask for any genetic disorder in the family members.

E) Menstrual History:- (before pregnancy)


▪Age at puberty.

▪Average duration of menstrual cycle.

▪Amount of blood loss during menstruation.

▪Any problem due to menstruation.

F) Obstetrical History:-
▪After delivery mother & child care-

▪Ask about previous pregnancies any problems experienced.


▪Ask for the intranatal & postnatal progress of the previous pregnancies.

▪Ask for the place of delivery of these pregnancy.

▪Enquire for the living children & their current health status as per the table
below-

Sr/no Year of POG at Type of Puerperium


delivery Time of delivery
Abortion delivery

▪ Status of Baby:-

Status at Sex Wt.205kg/ Present


normal weight Condition

LBW- low birth weight baby-

POG-Period of a gestation-

G) Family Planning-
▪Have you adopted a family planning method?

▪which method was adopted?

▪For how long did you use it?


▪why was it discontinued?

▪Have you ever had a side effect of that method?

▪Will you adopt any family planning method after delivery?

▪Which method you will adopt and why?

H) Investigation & Report:-


▪Blood group of the mother & her husband

▪Rh- factor- +,-, antigen antibody of the mother & her husband

▪UDRL of the mother & her husband

▪HIV status of the mother & her husband human Immunodeficiency disease.

▪Hbs Ag of the mother & her husband

▪Hb level on

▪Urine sugars & Albumin

▪Blood sugar

▪Glucose Tolerance Test (GTT)

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