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Gynae and Obstetric History Gynae and Obstetric History

Screening Tool Screening Tool

Family Planning Family Planning

Risks associated Risks associated

Notes Notes

Annexure A Annexure A

Request Consent Request Consent

Client Consent Client Consent

TTOs / Drug Chart TTOs / Drug Chart

Follow Up Visit Follow Up Visit

Safe Abortion Safe Abortion

Print Profile Print Profile

LNMP

22 Nov 2023

Cycle

28-30 days

GA by Date

5 weeks 0 days

Cycle Description

Regular

Age at menarche (first period)

Unsure

Weight

Unsure

Grav

Para

Number of Living Children

One

Currently Breastfeeding

Miscarriages

None

Stillbirths

None

Ectopic Pregnancies

None

Abortions: Spontaneous

None

Abortions: By Choice

None

Complication/illness during pregnancy

None

Pregnancy-induced anaemia

NVD

None

Caesarean

One

Caesarean Date

28/03/2023

Caesarean Reason

Placenta Preavia

Chronic Abdominal Pain

Previous Cervical Smear Date

N/A

Treatment Cervical Abnormalities

None

Cone Biopsy Date

N/A

STIs Date Diagnose

N/A

STIs Treatment

None

Previous contraception

Yaz

Previous contraception: Duration

Unsure

Reason for stopping/switching

Migraines

Current Contraception

Condoms

Current Contraception: Duration

Unsure

Is IUD + Implant in place

Notes on medical history as provided by client on admission

No Known Allergies.
Migraines = symptomatic treatment.
Home PT = Posiitve. + Breast Tenderness.

Previous procedure or medication to terminate pregnancy

None

Previous procedure or medication, prescribed or performed by

None

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