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Comprehensive Pregnancy Care
Following IMC & WHO Guidelines for Maternal Care
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Comprehensive Pregnancy Care Form (IMC & WHO Guidelines)
Personal Information
Mother's Full Name *
Age *
Height (cm) *
Current Weight (kg) *
Pre-pregnancy Weight (kg) *
Education Level
Select education level
Occupation
Select occupation
Annual Income
Select income range
Blood Type
Select blood type
Rh Factor
Select Rh
Marital Status
Select marital status
Marriage Duration
Pregnancy Details
Last Menstrual Period (LMP) *
Pregnancy Type
Select pregnancy type
Conception Method
Select conception method
This is a planned pregnancy
Number of Previous Pregnancies
Previous Miscarriages
Previous Abortions
Medical History
Chronic Conditions
Diabetes Type 1
Diabetes Type 2
Gestational Diabetes (previous)
Hypertension
Heart Disease
Asthma
COPD
Thyroid Disease (Hypo/Hyper)
Kidney Disease
Liver Disease
Autoimmune Disease
Depression
Anxiety
Epilepsy
Migraine
Arthritis
Osteoporosis
Cancer History
PCOS
Endometriosis
Known Allergies
Penicillin
Sulfa Drugs
Aspirin
Ibuprofen
Codeine
Latex
Peanuts
Tree Nuts
Shellfish
Fish
Eggs
Milk
Soy
Wheat
Sesame
Mustard
Celery
Lupin
Mollusks
Sulfites
Previous Surgeries
Appendectomy
Gallbladder Surgery
Hernia Repair
C-Section
Hysterectomy
Ovarian Surgery
Breast Surgery
Thyroid Surgery
Heart Surgery
Orthopedic Surgery
Laparoscopy
D&C (Dilation and Curettage)
Current Medications
Insulin
Metformin
Blood Pressure Medications
Thyroid Medications
Antidepressants
Anti-anxiety Medications
Asthma Inhalers
Birth Control Pills
Pain Medications
Vitamins
Iron supplements
Calcium supplements
Folic acid
Previous Pregnancy Complications
Gestational Diabetes
Preeclampsia
Eclampsia
Placenta Previa
Placental Abruption
Preterm Labor
IUGR (Intrauterine Growth Restriction)
Polyhydramnios
Oligohydramnios
Hyperemesis Gravidarum
Cholestasis
HELLP Syndrome
Postpartum Hemorrhage
Postpartum Depression
Cervical Incompetence
Antepartum Hemorrhage
Vaccination Status
Tetanus Toxoid (TT)
Hepatitis B
Influenza
COVID-19
Tdap (Tetanus, Diphtheria, Pertussis)
MMR (Measles, Mumps, Rubella)
Varicella (Chickenpox)
HPV
Family Medical History
Family History of Diabetes
Family History of Hypertension
Family History of Heart Disease
Family History of Thalassemia
Family History of Mental Health Issues
Current Vitals & Health Status
Blood Pressure (Systolic)
Blood Pressure (Diastolic)
Heart Rate (bpm)
Temperature (°F)
Respiratory Rate (/min)
Oxygen Saturation (%)
Blood Sugar (mg/dL)
Hemoglobin (g/dL)
Fundal Height (cm)
Fetal Heart Rate (bpm)
When were vitals taken?
Current Symptoms
Nausea
Vomiting
Fatigue
Headache
Back Pain
Heartburn
Constipation
Swelling
Shortness of Breath
Dizziness
Mood Changes
Sleep Issues
Breast Tenderness
Frequent Urination
Food Cravings
Food Aversions
Additional Notes about Current Health
Lifestyle & Diet Preferences
Smoking Status
Select smoking status
Alcohol Consumption
Select alcohol consumption
Tobacco Use
Select tobacco use
Exercise Frequency
Select exercise frequency
Diet Type
Select diet type
Cultural Diet Preferences
Stress Level (1-10)
Average Sleep Hours
Daily Water Intake (glasses)
Detailed Diet Preferences
Dietary Restrictions
Vegetarian
Vegan
Jain Vegetarian
Gluten-Free
Dairy-Free
Low-Sodium
Low-Sugar
Diabetic Diet
High-Protein
Low-Fat
DASH Diet
Food Allergies
Peanuts
Tree Nuts
Shellfish
Fish
Eggs
Milk
Soy
Wheat
Sesame
Mustard
Celery
Lupin
Mollusks
Sulfites
Meal Preferences
Traditional Indian
North Indian
South Indian
Bengali
Gujarati
Punjabi
Quick & Easy
Home-cooked
Spicy Food
Mild Flavors
Fresh & Raw
Cooked & Warm
Favorite Ingredients
Chicken
Fish
Mutton
Eggs
Paneer
Tofu
Dal/Lentils
Beans
Quinoa
Rice
Wheat/Roti
Vegetables
Fruits
Nuts
Seeds
Dairy
Coconut
Ghee
Current Supplements
Prenatal Multivitamin
Folic Acid
Iron
Calcium
Vitamin D
Omega-3/DHA
Vitamin B12
Zinc
Magnesium
Probiotics
Available Cooking Time
Select cooking time
Food Budget Range
Select budget range
Generate AI Analysis (IMC & WHO Guidelines)
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