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
H.b.:
Pallor:
Maturity:
Fundal Height (Weeks):
Presentation:
Lie:
Foetal Heart Rate:
Foetal Movement:
ART Eligibility Assessment (If applicable)
WHO Staging: CD4:
Urinalysis
Urine Microscopy
Urinary Albumin mg/dL
Glucose Measurement (Qualitative)
Urine pH
Urine Specific Gravity
Urine Nitrite Test
Urine Leukocyte Esterase Test
Urinary Ketone mg/dL
Urine Bile Salt Test mg/dL
Urine Bile Pigment Test
Urine Color
Urine Turbidity
Urine Dipstick for Blood
ARV Medication
Mother On:
Drug Dose Dose Units Frequency Duration Duration Units
Clinical Notes