Keep Records

it is importatant...
CASE PAPER FOR
MEDICAL (PILLS) TERMINATION OF PREGNANCY

Date -..............

Name of Patient - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 厖厖厖...

Age of Patient (completed years) - . . . . . . . . . . . . 厖厖厖... . .......

Name of Husband - . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . .,.......................

Age of Husband (completed years) - . . . . . . . . .. ..................................

Full Address-....................................... Village/Town.................
Post office-. . . . . . . . . . . . . . . . Taluka- . ...................... .. District-. . . . . . . . . . . . . . . . .

History -

Chief complaints - .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Married / Unmarried / widow, age - . .... . Completed years.
Obstetric History - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1......................... .2. .........................3. ........................ .4..........................

Total children (sex & age) .. . . . . . . . . . . . . . . . . . . . . . . . ... ................:.......
LMP - . . . . . . . . . . . . . . . . . . . Date of last delivery - . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Past illness - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Particular Family history - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .

Particular Personal history - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

History of drug or other allergies - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Examination - Weight in kg'-. . . . . . . . . .

Pulse - . . . . / minute. Blood Pressure' . . . . . . . . / . .. mm hg. Temperature - . . . . deg. F

General condition - . . . . . . . . . . . . . . . . . . . . . . .. Nutritional condition - . . . . . . . . . . . . .

No pallor, no ecterus, no pedal edema, / . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heart sounds - . . .,........ Respiratory system - . . . . . . . . .......................

Per abdominal - . . . . . . . . . . . . . . . . . . L - . . . . . . . . . . . S - . . . . . . . . . . . K - . . . . . . . . .

Other examination - . . . . . . . . . . . . . . . . . . . . . . .

P. V. examination - . . . . . . . . . . . . . . . ........ . Per Speculum exam - . . . . . . . . . . . . .

Any other - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Investigations - HB - . ...... .gm%, Blood group - .................Urine routine -. . . . . .

Any other - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical Abortion Therapy Details -

Day-l (Date - ...............) -................................

Day - 3 (Date - ....................) - ................................

Day-7 (Date - ....................) - .................................

Day – 15 ( Date - ……………) - …………………..

Confirmation of complete abortion is done by - clinical exam / ultrasound.
Advise given - ………………………………………

If case referred then

Name of Doctor in case of complication - ……………………………………

MTP center in case of failure - ……………………………

Final Remark -............................................... ........................ .......

Signature -........................... Date -.............................

Name of Doctor ………………………………….

Place - ……………………………………