5-Page ANC History Taking Format: Essential Guide for Perfect Assessments
Why ANC History Taking Matters?
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ANC History Taking - FORMAT
Socio-demographic Details (clinical significance)
- Name of the patient, partner’s name and address
- Education
- Socio-Economic information
- Family composition
- Nearest health facility_______
Current Pregnancy Profile:
- Obstetric Index: G__P__L__A__ (decoding gravida & Para)
- Last Menstrual Period (LMP): ______ Expected Date of Delivery (EDD): _______ (calculating EDD)
- Period of Gestation (POG): ______ weeks ______ days (Based on LMP/USG) (understand periods of pregnancy)
- Booking Status: Booked? ☐ Yes ☐ No : If yes, which facility: ______________________ (clinical significance)
Pre-conception History:
Planned Pregnancy? ☐ Yes ☐ No : Contraceptive Use Prior to Pregnancy: ________________
Blood Group & Rh: ______ ☐ Rh Positive ☐ Rh Negative
Presenting Complaints
There may not be any presenting complaint (PC) if she has come only for a routine antenatal checkup or has been admitted for delivery.
- If she has no complaints, simply record: “No presenting complaints; attending for routine ANC / scheduled follow-up / admission for delivery (as applicable).
If she has presented with some complaints, record these and the history of presenting illness (HOPI) as per following guidelines:
- List the presenting complaints (PC) in chronological order
- The PCs are listed along with the duration of onset
- PCs should be only in the patient’s language and not converted into medical terms
History of Presenting Complaints: (if any PCs)
HOPI involves exploring the presenting complaints in more detail like mode of onset, severity, duration, course over time leading to the current status, aggravating and relieving factors etc.
Trimester-wise History of Current Pregnancy
First Trimester (clinical significance)
Conception and Confirmation
- Was this a planned pregnancy?
- Did conception occur naturally or after fertility treatment?
- Gestational age at diagnosis: _____ days of amenorrhea
- Diagnostic method: Home urine test / Ultrasound
- Diagnostic location: _____
Maternal Health Events
- History of severe nausea and vomiting during early pregnancy
- Fever with skin rash
- Vaginal bleeding
- Radiation exposure
- Medications taken during this period
Screening and Assessment
- Completion status of first trimester investigations and dating ultrasound
- Results reported as: Normal / Abnormal (specify) / Pending
Any other symptom: ______________________________
II. Second Trimester (clinical significance)
Clinical Monitoring
- Number of antenatal visits attended
- Date fetal movements first perceived: _____ weeks gestation
- Tetanus (Td) immunization: _____ doses at _____ weeks gestation
Nutritional Support
- Iron supplementation
- Calcium supplementation
Maternal Symptoms Requiring Attention
- Vaginal bleeding episodes
- Symptoms suggestive of pre-eclampsia:
o Excessive weight gain: Rapid or unusual weight gain
o Lower limb swelling
o Reduced urination
o Headache
o Visual disturbances
o Upper abdominal discomfort
Diagnostic Screening
- Gestational diabetes screening: Completed / Pending / Not done
- Fetal structural assessment ultrasound: Completed (normal / abnormal) / Pending / Not done
Any other symptom: ______________________________
III. Third Trimester (clinical significance)
Clinical Monitoring
- Number of antenatal visits attended
Maternal Symptoms Requiring Attention
- Signs suggesting high blood pressure complications:
o Rapid or unusual weight gain
o Lower limb swelling
o Reduced urination
o Headache
o Visual disturbances
o Upper abdominal discomfort
- Fetal movement assessment: Reported as normal / reduced / absent
- Vaginal fluid leakage
- Vaginal bleeding
Nutritional Support
- Iron supplementation: Ongoing / Discontinued
- Calcium supplementation: Ongoing / Discontinued
Associated Symptoms
- Abdominal pain: Present / Absent (if present, describe nature and location)
- Urinary symptoms
- Bowel disturbances
Any other symptom: ______________________________
Menstrual History (MH) (ANC history - significance of Clinical Components)
(Conclude menstrual history with the LMP.)
Marital History
Married for last ______ years; Consanguineous/ Non-consanguineous marriage
- If consanguineous: Degree of consanguinity – first degree/second degree/ third degree
Past Obstetric History
History of Abortion (If Applicable)
- Pregnancy confirmed by __________ at ______ days of amenorrhea
- Type of abortion: Spontaneous / Induced
- If induced—Reason: _____________________________________
- POG at abortion: __________________
- Method: Medical / Surgical
- Post‑abortal complications (fever, foul discharge, bleeding): __________________
- Return of menstruation: __________________
- Contraception used after abortion: __________________ (Duration: ______)
Past History:
| Obstetric case | Children | Adolescent | Elderly |
|---|---|---|---|
| Gravidity and parity Trimester wise history Past obstetric history Past gynecological history |
H/O Danger signs | Home environment | Four ‘Geriatric Giants’ Memory loss Depression Urinary Incontinence Falls/immobility |
| Gravidity and parity Trimester wise history Past obstetric history Past gynecological history |
Prenatal Natal Postnatal Feeding Developmental and Immunization history |
Educational/ employment history Physical activity and hobbies Drugs and alcohol History suggestive of suicide ideation and depression Violence & injury Sexuality H/o sexual relations Condom use Contraceptive use History of STD Other sexual issues |
Four ‘Geriatric Giants’ Memory loss Depression Urinary Incontinence Falls/immobility |
| Gravidity and parity Trimester wise history Past obstetric history Past gynecological history |
Prenatal Natal Postnatal Feeding Developmental and Immunization history |
Educational/ employment history Physical activity and hobbies Drugs and alcohol History suggestive of suicide ideation and depression Violence & injury Sexuality H/o sexual relations Condom use Contraceptive use History of STD Other sexual issues |
Joint pain Dysuria/nocturia/frequency/urgency of micturition Hearing loss Breathlessness, Orthopnoea Vision, symptoms of cataract and glaucoma Polyuria, polydipsia etc. to r/o DM Symptoms to r/o cancers like haemoptysis, blood in urine, vaginal bleeding after menopause, seizures, blood in stool, etc. Neuropathies: abnormal sensation/ loss of sensation in any limb |
| Gravidity and parity Trimester wise history Past obstetric history Past gynecological history |
Prenatal Natal Postnatal Feeding Developmental and Immunization history |
Educational/ employment history Physical activity and hobbies Drugs and alcohol History suggestive of suicide ideation and depression Violence & injury Sexuality H/o sexual relations Condom use Contraceptive use History of STD Other sexual issues |
Economic dependence Caregiver esp. during illness Abuse/ neglect |
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Contraceptive History
- Contraceptive use before first pregnancy
- Contraception use for spacing _____________________________________
- Contraception before the Current Pregnancy
- Any contraceptive method used immediately before conception: Yes / No
- If yes—Method, duration, and time of stopping: ___________________________
- Pregnancy despite using contraception? Yes / No
Personal History
- Tobacco chewing, cigarette smoking, alcohol, coffee, cola, tea
- Vegetarian/Non Vegetarian:
o Allergies to any food item
- Sleep/Rest: No. of hours in night & daytime
- Bladder and bowel habits
- Occupation: Nature of work
- Ask about the patient’s current
- Domestic abuse: Ask in confidential, safe space
Dietary History
Diet Type: Mixed / Vegetarian / Vegan / Other: _______________________________
Assess the patient’s routine dietary pattern, with emphasis on a 24-hour dietary recall to estimate calorie, protein, and iron intake accurately. Summarize the findings follows:
- Estimated Calorie Intake: ______ Kcal, which is adequate / or ____% below / ____% above the recommended daily requirement.
- Estimated Protein Intake: ______ g, which is adequate / or ____% below / ____% above the recommended daily requirement.
- Any allergy or food intolerance
Family History
Details (if any): _______________________________________________
Details regarding 'Birth Preparedness and Complication Readiness (BPCR) ___________
Summarize the History
- Name: _____ Age: ____ G P L A: ____ LMP: ______ EDD: ______ POG:___weeks
- Key Complaints: _____________________________________________
- Significant Positives/Negatives: _______________________________
- Complications (if any): _______________________________________
- Risk Categorization: ☐ Low-risk ☐ High-risk
Suggested investigations and management plan:
___________________________________________________________________
References:
- Ministry of Health and Family Welfare, Government of India. Guidelines for Antenatal Care and Skilled Attendance at Birth, 2010
- Dutta DC. Textbook of Obstetrics. 9th ed. New Delhi: Jaypee Brothers Medical Publishers; 2023.
- Padubidri VG, Daftary SN. Shaw’s Textbook of Gynaecology. 18th ed. New Delhi: Elsevier; 2022.
- Park K. Park’s Textbook of Preventive and Social Medicine. 28th ed. Jabalpur: Bhanot Publishers; 2025.
- Babu SA. Clinical Obstetrics and Gynecology. 2nd ed. New Delhi: Wolters Kluwer India Pvt Ltd; 2025
5-Page ANC History Taking Format: 5-Page ANC History Taking Format: Essential Guide for Perfect Assessments
Pallor and its Grading
Why ANC History Taking Matters?
#Obstetric index (GPAL) in Antenatal Case History: Obstetric index (GPAL) in Antenatal Case History
#Decoding Gravida and Para: Terms in Antenatal History Taking: Decoding Gravida and Para: Terms in Antenatal History Taking
#Duration of Pregnancy: Understanding the Trimesters and Gestational Age Categories: Duration of Pregnancy: Understanding the Trimesters and Gestational Age Categories
#Calculation of Expected Date of Delivery (EDD) and Period of Gestation (POG): Calculation of Expected Date of Delivery (EDD) and Period of Gestation (POG)
#Antenatal Care and Case Booking: Antenatal Care and Case Booking
#Clinical Significance of Antenatal History Components (Socio-Demographic components): Clinical Significance of Antenatal History Components (Socio-Demographic components)
Antenatal History Taking: Significance of Clinical Components
Trimester-wise History Taking in Antenatal Care: FIRST Trimester
Trimester-wise History Taking in Antenatal Care: SECOND Trimester
Trimester-wise History Taking in Antenatal Care: THIRD Trimester
Trimester-wise History Taking in Antenatal Care: A Comprehensive Guide (all 3 trimesters))
Components of Birth Preparedness and Complication Readiness (BPCR)
BPCR in brief: ‘Birth Preparedness and Complication Readiness’ (BP/CR)
Specific Health Protection during Antenatal Visits