Maternal Health Risk Assessment Form
Personal Information
Full Name
Age
Address
Contact Number
Pregnancy Information
Gravida (Number of pregnancies)
Para (Number of births after 20 weeks)
Last Menstrual Period (LMP)
Estimated Due Date (EDD)
Medical and Obstetric History
Previous Complications
Preterm Labor
Cesarean Section
Preeclampsia/Eclampsia
Hemorrhage
Gestational Diabetes
Other
Other Medical History
Current Pregnancy Risks
Current Symptoms
Vaginal Bleeding
Abdominal Pain
Fever
Severe Headache
Blurred Vision
Swelling
Other
Known Risk Factors
Lifestyle and Social Factors
Smoking
Yes
No
Alcohol Use
Yes
No
Support System