OBSTETRIC & GYNAECOLOGY REPORT (To be completed by Obstetrician & Gynaecologist) Proposal/ Policy No.

Age

Name LMP

EDD

Gestational Age at Booking Date (in weeks)

Current Gestational Age (in weeks)

Current Weight (kg)

Weight at Booking (kg)

Blood Type

Date of Last Follow-up

Gravida

+

Para

Rhesus

Part A: Previous Pregnancy (including miscarriage and abortion) No

Year

Current Child’s Age/ Gestational Age (If miscarriage/ abortion)

Gender

Birth Weight (kg)

Complication (Mother / Child)

Part B: Family History (including congenital and genetic disorders)

No

Relationship

Self Disease/Disorder

Age at Onset

Relationship

DETAILS – PLEASE GIVE FULL DETAILS IF ADVERSE FINDINGS AND OPINIONS Spouse Disease/Disorder

Part C: Past or Present Medical / Obstetrics History Is there any history of, or do you find any evidence of any disease or abnormality of: A)

Excessive weight gained during pregnancy period, Per Vagina (PV) spotting or haemorrhage?

B)

Pregnancy induced hypertension / Pre-eclampsia/ Eclampsia?

C)

Gestational Diabetes Mellitus?

D)

Glycosuria or Any other abnormal urine test?

E)

Anaemia?

F)

Cervical Incompetence?

G)

Placenta (including abruptio placenta, placenta previa)?

H)

UTI? Intra-uterine infection? Leakage of liquor?

I)

Premature uterine contraction?

J)

Intra-uterine growth retardation? Inter-uterine demise?

K)

Genito-urinary system (including pelvis mass, uterine abnormalities)?

L)

Any other abnormalities, which are not mentioned above?

M)

General Health: Does insured suffered from any general health condition, since prior to pregnancy?

Doc ID 10201065

Child’s current health condition

Age at Onset

Yes No Ya Tidak

DETAILS – PLEASE GIVE FULL DETAILS IF ANSWERED ‘YES’ AND / OR ADVERSE FINDINGS

Version 07/2013

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Yes No Ya Tidak

Part D: Fetal Assessment (including examination, ultrasound, nuchal translucency) Is there any or do you find any evidence of past or present disease or abnormality of: A)

Fetal growth (including bi-pariental diameter, femur length & abdominal circumference) / Fetal Weight?

B)

Liquor volume (polyhydromnios or oligohydromnios)?

C)

Fetal heart or Fetal movement?

D)

Any other fetal anomalies?

E)

Any blood screening, amniocentesis, triple test, genetic studies done?

F)

Any other abnormalities, which are not mentioned above?

DETAILS – PLEASE GIVE FULL DETAILS IF ANSWERED ‘YES’ AND / OR ADVERSE FINDINGS

Part E: Ultrasound Findings (2D/3D/4D): Type of Ultrasound Done:

2D

3D

4D

Gestational Age as per Ultrasound: Are there any abnormal findings?

Yes

No

Yes

No

Yes

No

Please provide details of the ultrasound findings:

Part F: Doctor’s Additional Information (as supplementary comment and / or abnormality not mentioned above)

Note: Please attach all the investigation reports performed (including blood test, urine test, ultrasound and etc.)

Signature of doctor :

Date :

Name of doctor :

Clinic stamp:

Doc ID 10201065

Version 07/2013

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