Date: Provider: Location:
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Vitals
Temperature
Pulse Rate
B.P. / mmHg
Respiratory Rate
Oxygen Saturation
Weight
Height
BMI
MUAC
Other Vitals Recorded Recently

Temperature:
Pulse:
B.P.: /
Respiratory Rate:
Oxygen Saturation:
Weight:
Height:
MUAC:
Other Observations
General Condition:
Breast
C/S Scar
Involution of Uterus
Condition of Episiotomy
Lochia
Haemoglobin
Mother's HIV Status
Baby's Condition
Baby's Feeding Method
Umbilical Cord
Baby Immunization Started
Counseling on Family Planning
Pelvic Exam
Uterus Examination
Uterus Cervix Examination
Vaginal Examination
Parametrial Examination
External Female Genitalia Examination
Ovarian Examination
Pelvic Lymph Node Examination
ARV Medication
Mother On:
Drug Dose Dose Units Frequency Duration Duration Units
Clinical Notes