Download mtrh - antenatal care initial encounter form (anc1)

Date: _dd_/_mm__/_yyyy__
MTRH - ANTENATAL CARE INITIAL ENCOUNTER FORM (ANC1)
Names: (First, Middle, Surname)
MTRH No/AMRS ID:
Marital Status:  Single  Married  Divorced  Widowed  Separated
DOB: dd /mm / yyyy OR Age:____yrs
District:
Location/Sub-location:
Village/Estate:
Phone No:
Partner’s Phone No.:
Education Level:  None  Primary  Secondary  College  University
Partner’s name:
Occupation:
Partner’s occupation
Partner’s Age:____yrs
1. Menstrual & Contraceptive history
L.N.M.P date___/___/____
EDD:
__/___/____
2. Past Obstetrical history
2. Contraception used (most recent):  None
 Natural
 IUD
 Progestin pills
 Traditional  Condoms
 Implants  Depo-Provera
 Combined hormone pills
Gravida:_______
Parity: ________+_________
Gestation at
Location
D.O.D
Outcome:
delivery/
(Home or
dd/mm/yy
(Live/still-births,
Miscarriage
Health
yy
ectopic, e.t.c)
(mos)
Facility)
3. Had Ultrasound this
pregnancy? Yes  No
Sex
Length
Mode of
Birth
of
of labor delivery (SVD,
weight
child
(hrs)
VAC, CS)
(kg)
(M,F)
Complications
(maternal, fetal, child)
5. Current pregnancy history (Check each case); REFER TO CONSULTANT IF YES
Excessive Nausea and Vomiting
Y N Abnormal Vaginal discharge
Y
N
Severe Headache
Y
N
Vaginal bleeding
Y
N
Severe Swelling of hands/face
Y
N
Uterine contractions
Y
N
Fever
Y
N
Foetal movements:  Adequate  Reduced  Absent
Dysuria:
Y
N
Cough:
Y
N
Days
Weeks
 N/A (<20
wks)
Months
Genital ulcers
Y
N
Night sweats:
Y
N
Days
Weeks
Months
6. Medical history for woman (If Yes, complete ‘Comment’)
Thyroid
Y
N
Abnormal PAP smear
Y
N
History of blood transfusion
Y
N
Diabetes
Y
N
Thromboembolic disease / blood clots
Y
N
Congenital anomalies in
newborns
Y
N
Hypertension/ High BP
Y
N
Urinary tract infections (UTI)
Y
N
Anemia
Y
N
Yellowness of eyes
Y
N
Seizure disorder
Y
N
Breast disorder
Y
N
Heart disease
Y
N
Problems with anesthesia
Y
N
Drug allergies
Y
N
Asthma
Y
N
Multiple preg. in maternal family
Y
N
Hospitalizations
Y
N
Comment / Others……………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………….
History of Infectious Diseases (If Yes to Hx of STD, tick all that apply)
 Cervicitis, non specific
 PID
 GUD
 Genital warts
7. Hx. Sexually Transmitted
Diseases. Yes  No
 Gonorrhea
 Herpes
 Syphilis
 Chlamydia
 Trichomonas
8. Tuberculosis: Yes No
9. Medications (Please indicate all medications the patient is taking, tick all that apply)
 None
 Vitamins
 Iron/ Fe
 Folate
 ARV’s
 Malaria prophylaxis
 Cotrimoxazole/ Septrin
 Other (Specify)
MTRH – Antenatal Care Initial Encounter Form. Version 2.2 15th Aug 2011
Psychosocial history
10. Barriers to proper health care  Yes  No If Yes, tick all that apply
 Housing/ shelter
 Communication
 Transportation
 Child care
 Money/ finances
 Work commitments
 Unplanned pregnancy
 Other……………………………………………..
 Spouse / family
11. History of postpartum depression or other mental health problems? Yes No
12. Substance use?
Alcohol
Y N Cigarettes
Khat (miraa)
Y N Aerosol/ glue
13. Patient education Checklist (Tick when completed)
 Weight gain / Nutrition
 Mode of delivery
 Contraception
 Sexual activity
 Use of medications
 Work
Birth plan
14. Do you know when the baby will be born?
16.Indicate preferred infant feeding option
Y
Y
N
N
Cannabis (bhangi)
Intravenous (IV)
 Signs of labor
 Fetal movement
Y
Y
N
N
 PROM/ APH
 Infant feeding
15. Preferred mode of delivery SVD Elective CS
Yes No
 Exclusive breast feeding
 Expressed breast milk
 Formula
 Animal milk
17. Who will be present for social support during delivery?  Husband/ Partner
 Sibling
 Parents
 Parents in-law
 Grandmother
 Children
 Other……………………………………………
18. Will you deliver at a health facility?
If No, why?
 Yes  No
If Yes, Where?  MTRH  Other………. …………………..
 Lack of transport  Culture  Family Health worker’s attitude  Cost  Other………………………
19. Do you have emergency transport plan?
 Yes  No
 Yes  No
20. Do you have insurance or NHIF?
21. Physical examination
Head / Neck
Temp:________ HR:___________ BP _______/_______
 Normal
 Abnormal (See comment)
Wt:________(Kgs)
Ht:_____ ____(cm)
CVS (Cardiac)

Normal
 Pallor
 Normal
General
 Abnormal (See comment)
 Jaundice
 Oedema
 Lymphadenopathy
Breast exam
RS (Respiratory)
 Normal
 Mastitis
 Normal
 Abnormal (See comment)
 Cracked nipples
 Lump
 Other
Genital exam
 Normal
 Ulcer
 Not done Comment:
 Vaginal discharge
 Warts
 FGM
Uterus:
Presentation:  Cephalic Other
Fundal ht: ________cm
Fetal HR:_________bpm Specify……………………………………………………………………..
22. Results of TODAY’S Laboratory Testing;
Urine Screen: Protein Nil + ++ +++ Glucose Nil + ++ +++ Leukocytes Nil + ++ +++
Blood group/ABO :  A
Hemoglobin:_________g/dL
B
 AB
O
Syphilis/ VDRL:
 Pos  Neg
Random blood sugar: _______mmol/L
23. Counselled on HIV: Yes No  N/A
24. Tested for HIV: Yes No
Antibody screen:  Pos  Neg
PBS for MPS:
 Pos  Neg
HIV results:
 Pos  Neg
Other:……………………………………………………………………………………………………………………………
25. Drugs prescribed/given this visit
Dose
Frequency
Duration
Picked up
1. Cotrimoxazole








2. Fe Supplement
3. Folic Acid
4.
5.
6.
7.
8.
26. Rh Pos Neg
Out of Stock
If Neg, Indirect Coomb’s Test (ICT) at 28 weeks
If Neg.(ICT), Anti-D Rh IgG given at 28 weeks
27. TT given to date: Non  TT1  TT2  TT3  TT4  TT5
TT Given today:  Yes  No
Referrals
TT Complete:  Yes  No
Referrals:  None  Obstetric consultant








Pos
Neg.
 N/A <28 wks
Yes
No
28. IPT1:  Yes  No
IPT2:  Yes  No
29. Insecticide Treated Net  Yes  No
 Social Work  Nutritionist
 AMPATH  Other: ___________________________________
Reason for Referral________________________________________
Return to Clinic: Date:_______/________/__________
Provider:_________________________
Signature:______________________
Provider #:_________________
MTRH – Antenatal Care Initial Encounter Form. Version 2.2 15th Aug 2011
MTRH – Antenatal Care Initial Encounter Form. Version 2.2 15th Aug 2011