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(Kindly fill the relevant information or tick, as appropriate.)

Name of Doctor: *

ID No.

Patient Initials*

Age (years) *

Weight (kgs)*

Date of Visit*

<28 weeks 28-32 weeks 32-37 weeks

Past Obstetric History *
Previous Pregnancy	Yes No
Complications with Previous Pregnancy	Yes No Not Applicable
If yes, details of complications with previous pregnancy
1. Mother
2. Baby
Gravidity	0 1 2 3 4 ≥5
Parity	0 1 2 3 4 ≥5
Number of living children	0 1 2 ≥3
Number of abortions	0 1 2 3 4 ≥5
In Patients with history of preterm birth, number of preterm birth	1 2 ≥3

Physician assessment
Parameter	Term Pregnancy (After 37 weeks of gestation) Preterm Delivery between 34 to 37 weeks of gestation Preterm Delivery (Before 34 weeks of gestation)
Physician assessment on tolerability	Excellent Very good Good Satisfactory Poor
Physician assessment on route & dosage convenience	Excellent Very good Good Satisfactory Poor

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