DREAM Forms

Form Id: FRM_RCA_GROSSES

positive for syphilis, received treatment (date):
Option B+ (date):
ARV less than 4 weeks before delivery (date):
Partner tested for HIV (date):
Partner tested for HIV Positive:
Tested for malaria (date):
Tested for Malaria Positive:
Pre Natal Cons. 1 - Fansidar (date):
Pre Natal Cons. 2 - Fansidar (date):
Pre Natal Cons. 3 - Fansidar (date):
Pre Natal Cons. 4 - Fansidar (date):
Mosquito net received (date):
Obstetric background
pregnancies:
Deliveries:
Stillbirths:
Abortions:
Born alive:
Currently alive:
Deceased:
Vaccination
Tetanus Vaccination (1st dose):
Tetanus Vaccination (2nd dose):
Tetanus Vaccination (3rd dose):
-
Maternity facility where she was sent for delivery:
Obstetric history
Previous twin pregnancy ***:
Previous births with suction cup ***:
Bleeding complications in previous births? ***:
Manual removal of the placenta in previous births? ***:
Caesarean section in the last birth? ***:
First pregnancy and under the age of 16? ***:
age over 35? **:
Breech presentation in previous births ***:
Had 5 or more births ***:
Last pregnancy: stillbirth? ***:
Last pregnancy: did the newborn die during the 1st week? **:
Did you have 2 or more miscarriages or stillbirth? **:
Have you had a newborn weighing more than 4 kilos? **:
Have high B. P. or edema in previous pregnancies? **:
Did you have seizures in previous pregnancies? **:
Did you have seizures in the absence of pregnancy? *:
Are you very hungry, thirsty and urinate a lot?:
Do you have dysuria and pollakiuria?:
Have you had a cough and expectoration for more than two weeks?:
Do you have tuberculosis and are you undergoing treatment?:
Did you have PTV in previous pregnancies?:
* Cuidados de saúde primários
** Cuidados de saúde secundários
*** Cuidados de saúde terciária

Note: Any gray lines, in production, will be enabled under pre-set conditions, but this functionality does not work in this preview

Form Preview