Astha Hospital | OPD Doctor Notes

1st Trimester Consultation

4–12 Weeks of Pregnancy

Clinical History

GESTATIONAL AGE

WEIGHT

COMPLAINTS

O/E

P/A

P/V

Investigations

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

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

Irregular Periods Consultation

Infertility Consultation

General Gynecology Consultation

Menopause / Perimenopause Consultation

PCOS Consultation