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HIS2KRGANC1 |
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Republic
of Namibia |
Ministry
of Health and Social Services |
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Rev. 08/00 |
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Antenatal
Clinic/Care |
(ANC ) Register |
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NOTE: Summary data from
shaded cells to be recorded on Tally Sheet/Monthly Report Form |
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- - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - F I R S T V I S I T - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - |
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-
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - F
I R S T A N D F O L L O W - U P V I S I T S - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
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Client No: |
Visit |
Patient Name |
Address/Place |
Age |
Gravida |
Para |
Date |
EDD |
Trimester |
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TT2 Already |
RPR |
Pap |
High Risk Factors/ |
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Weight |
B/P |
Urine |
Hgb |
HOF |
FHR |
Pre- |
TT Dose |
Referred? |
Comments/ |
Date |
Provider |
Provider |
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LNMP |
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At 1st Visit |
OR Given |
Test |
Smear |
Danger Signs |
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sen- |
Given |
(If So, Why? |
Treatment |
Of |
Name |
Signature |
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1st Visit |
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tation |
(No. of |
Where?) |
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Next |
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Date |
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1 |
2 |
3 |
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Dose) |
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Visit |
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1 |
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Date |
Date |
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1 |
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1 |
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2 |
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Results |
Results |
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2 |
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2 |
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3 |
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3 |
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3 |
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4 |
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4 |
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4 |
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5 |
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5 |
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5 |
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6 |
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6 |
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6 |
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Client No: |
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Date POSTNATAL Visit Made |
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Date |
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1 |
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Date |
Date |
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1 |
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1 |
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2 |
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Results |
Results |
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2 |
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2 |
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3 |
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3 |
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3 |
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4 |
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4 |
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4 |
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5 |
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5 |
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5 |
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6 |
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6 |
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6 |
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Date POSTNATAL Visit Made |
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