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Section B
Section C
Section D
Section E
Section F
Section G
Section H
Section I
Section J
Section K
Section L
Section M
Section D
Pregnancy details of the mother
Illnesses before pregnancy:
Diabetes
Hypertension
Heart Disease
Epilepsy
Any other (Specify)
Illness during pregnancy:
Gestational Diabetes Mellitus
Hypertension
Infection with fever
Disease causing
Other (specify)
Folic acid supplementation,
Did you take any folic acid before pregnancy?
Yes
No
How many months before pregnancy did you take folic acid?
Months
What were the supplementations during pregnancy that you took? If taken were they taken daily or on and off?
Taken
If yes, compliance
Daily
4-6 times a week
3 times or less than 3 times a week
Iron
Folate
Calcium
Vitamin C
Multivitamin
Food Supplementation (Triposha)
Maternal hemoglobin:
POA (in weeks)
Results ( in g/dl)
Maternal weight gain: check with the pregnancy record
POA (in weeks)
First record (Before 12 weeks)
Second(12-28 weeks)
One before the last record
Last record in the pregnancy record
POA (in weeks)
Weight (Kg)