Astha Hospital | OPD Doctor Notes

1st Trimester Consultation

4–12 Weeks of Pregnancy

Clinical History

GESTATIONAL AGE

WEIGHT

PULSE

COMPLAINTS

O/E

P/A

P/V

2nd Trimester Consultation

13–27 Weeks of Pregnancy

Clinical History

GESTATIONAL AGE

WEIGHT

PULSE

COMPLAINTS

O/E

P/A

P/V

Diagnosis / Clinical Impression

Advice / Instructions

3rd Trimester Consultation

28–40 Weeks of Pregnancy

Clinical History

GESTATIONAL AGE

WEIGHT

PULSE

COMPLAINTS

O/E

P/A

P/V

Dysfunctional Uterine Bleeding

Abnormal Uterine Bleeding Assessment

Menstrual History

Bleeding Pattern

Bleeding Duration

Dysmenorrhoea

LMP

H/O Illness / Surgery / Drug Allergy

Obstetric History

O/E

P/A

P/V

Diagnosis / Clinical Impression

Advice / Instructions

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

Polycystic Ovary Syndrome Assessment

Menstrual History

Cycle / Frequency

Flow

LMP

H/O Illness / Surgery / Weight Gain / Hirsutism

O/E

Pulse

P/A

Diagnosis / Clinical Impression

Advice / Instructions

SR.	MEDICINE NAME	GENERIC NAME	DOSE	FREQUENCY	DURATION	INSTRUCTION	DEL.

Investigations

Follow Up

Next Visit

Follow Up Note

Old / Follow-up Patient

1st Trimester Consultation

2nd Trimester Consultation

3rd Trimester Consultation

Dysfunctional Uterine Bleeding

Irregular Periods Consultation

Infertility Consultation

General Gynecology Consultation

Menopause / Perimenopause Consultation

PCOS Consultation