INTERVIEW FORM FOR A PREGNANT CLIENT
Name of Interviewer : ____________________________________
Date of Interview
: _____________________
I.
Patient Profile
Name of Client:
Age:
Civil Status:
Occupation:
Address:
Gravidity
Parity
LMP
EDD
II.
: ______
: ______
: ______
: ______
AOG
Fundal Height
Fetal Heart Rate
: _________
: _________
: ________
Signs of Pregnancy
a. Presumptive Signs
1st Trimester
 Amenorrhea
 Nausea
 Vomiting
2nd Trimester
 Quickening
 Chloasma



Breast Changes
Fatigue
Urinary Frequency


Linea Nigra
Striae Gravidarum
b. Probable Signs
1st Trimester
 Positive HCG
nd
2 Trimester
 Braxton Hicks Contractions
 Enlarged Abdomen
c. Positive Signs
1st Trimester
 Ultrasound
 Fetal Heart Tone Heard
III.
Fetal Movements
Fetal Outline on Ultrasound







Striae Gravidarum
Yeast Infection
Constipation
Backache
Dizziness
Headache
Muscle Cramps
Discomforts of Pregnancy







IV.


Nausea & Vomiting
Fatigue
Hemorrhoids
Varicosities
Heartburn
Bleeding Gums
Edema
Obstetric History
a.
b.
c.
d.
Number of Pregnancies : ________________
Number of Miscarriages : ________________
Length of Pregnancies : ________________
Date of Delivery
: ________________
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e. Place of Delivery
: ________________
Type of Labor
: _____ Spontaneous
f.
g.
h.
i.
V.
Mode of Delivery
:
Sex of Newborn
: _____ Female
Birth weight
: ___________
Complications: _______________
______ Induced
_______ Male
Gynecological History
a. Past Illness
: ______________________
b. Hospital Admissions
When?
: ______________________
Where?
: ______________________
Why?
: ______________________
c. Surgical Procedures
 Abdominal Procedures
 Problems with Anesthesia
 Problems with Bleeding (requiring transfusion)
d. Menstrual History
Cervical Smear History
Coital Problems
Regular Menstrual Cycle
e. Method of Contraception
Type
:
Length of Usage
:
Remarks
:
:
:
:
____ Yes
____ Yes
____ Yes
____ No
____ No
____ No
________________
________________
________________________________________________________
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