Prenatal Physical Examination Form

Personal Information

Full Name Date of Birth Patient ID Date of Exam

Vital Signs

Blood Pressure (mmHg) Pulse (bpm) Respiratory Rate (per min) Temperature (°C) Weight (kg) Height (cm)

Obstetric History

Gravida Para Last Menstrual Period Estimated Due Date

Physical Examination

General Appearance Head/Neck Heart Lungs Abdomen (Fundal Height, Fetal Heart Tones, Fetal Movement) Extremities (Edema, Varicosities) Pelvic Exam

Laboratory/Screenings

Hemoglobin Urinalysis Blood Type/Rh Other Labs

Assessment & Plan

Assessment Plan/Recommendations