Astha Hospital | OPD Doctor Notes

1st Trimester (4–12 Weeks of Pregnancy)

As per Dr. Harshada Patil handwritten OPD format

▤ Clinical Details

▦ Gestational Age

◉ Weight (kg)

—

♥ BP (mmHg)

—

✎ Complaints

⌁ O/E & Examination

✚ O/E

◐ P/A

♀ P/V

✓ ADVICE / INSTRUCTIONS

2nd Trimester Consultation

Template driven

Gest. Weeks

Gest. Days

Fetal Movement

Fundal Height

FHS

Presentation

Current Complaints

Obstetric Examination

Anomaly Scan / USG Findings

Diagnosis

Advice / Supplements

Additional Notes

3rd Trimester Consultation

Template driven

Gest. Weeks

Fetal Movement

Fundal Height

FHS

Presentation

Complaints

Obstetric Examination

Growth Scan / NST / USG

Diagnosis

Birth Plan / Advice

Warning Signs

Irregular Periods Consultation

Template driven

LMP

Cycle Length

Duration

Flow

Dysmenorrhea

Intermenstrual Bleed

Acne

Hirsutism

History

USG / Hormonal Findings

Diagnosis

Plan / Advice

Infertility Consultation

Template driven

Marriage Duration

Infertility Duration

Type

Previous Treatment

Partner History

AMH

TSH

Prolactin

Semen Analysis

USG / HSG / Ovulation

Assessment / Diagnosis

Plan

General Gynecology Consultation

Chief Complaints

History

Clinical Examination

Diagnosis

Advice

Menopause / Perimenopause Consultation

LMP

Hot Flushes

Sleep Disturbance

Vaginal Dryness

History

Diagnosis

Plan / Advice

PCOS Consultation

Cycle Length

Acne

Hirsutism

Weight Change

USG Findings

Hormonal Findings

Diagnosis

Plan / Advice

Prescription

Sr.	Medicine (Brand Name)	Generic Name	Dose	Frequency	Duration	Instruction	Action

Investigations

Follow Up

Next Visit

Follow Up Note

OPD Doctor Notes

Old / Follow-up Patient

1st Trimester (4–12 Weeks of Pregnancy)

2nd Trimester Consultation

3rd Trimester Consultation

Irregular Periods Consultation

Infertility Consultation

General Gynecology Consultation

Menopause / Perimenopause Consultation

PCOS Consultation

Prescription

Investigations

Follow Up