Why ANC History Taking Matters?
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ANC History Taking - FORMAT
Socio-demographic Details
• 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__
• Last Menstrual Period (LMP): ______ Expected Date of Delivery (EDD): _______
• Period of Gestation (POG): ______ weeks ______ days (Based on LMP/USG)
• Booking Status: Booked? ☐ Yes ☐ No : If yes, which facility: ______________________
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
I. First Trimester
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 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 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)
(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:
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): _______________________________________________
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:
1. Ministry of Health and Family Welfare, Government of India. Guidelines for Antenatal Care and Skilled Attendance at Birth, 2010
2. Dutta DC. Textbook of Obstetrics. 9th ed. New Delhi: Jaypee Brothers Medical Publishers; 2023.
3. Padubidri VG, Daftary SN. Shaw’s Textbook of Gynaecology. 18th ed. New Delhi: Elsevier; 2022.
4. Park K. Park’s Textbook of Preventive and Social Medicine. 28th ed. Jabalpur: Bhanot Publishers; 2025.
5. Babu SA. Clinical Obstetrics and Gynecology. 2nd ed. New Delhi: Wolters Kluwer India Pvt Ltd; 2025