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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:
CPN1 Fansidar (date):
CPN2 Fansidar (date):
CPN3 Fansidar (date):
CPN4 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 aged 16 years? ***:
plus de 35 ans ? **:
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? **:
have seizures in previous pregnancies? **:
Did you have seizures in the absence of pregnancy? *:
Are you very hungry, thirsty and urinate a lot? *:
Tem dysúria and polaquiúria? *:
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

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