The MOTHER Initiative - Antenatal Visit

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Date of Visit

Gestation in Weeks (number)

B. EXAMINATION

Weight

kg

Temperature

C

Pulse

BP Systolic

BP Diastolic

SFH Fundal Height (weeks)

Fetal Heart Sounds Present

Yes No

Fetal Heart Rate

Fetal Movement

Yes No

General
Condition

Routine Care Further Assessment Required

D. PREVENTIVE MEASURES

Tetanus Toxoid (TT) Immunisation

Yes No

Iron/Folate Tablets

Yes No

Anti-malarial Treatment SP/IPT

Yes No

De-worm with Anti-helminthics

Yes No

HIV/ART

Yes No

ITN (Bed Net)

Yes No

Counsel for:

Nutrition

Yes No

Emergency Preparedness

Yes No

Breastfeeding

Yes No

Birth Spacing

Yes No

Notes

Birth Plan Developed

Yes No

Date of Next Visit

E. Actions Taken

Birth Plan Developed

Management Referral

Notes

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