New Pregnancy 12345 Person's ID Ask the mother if she has any of the following risk factors Is this your first pregancy? r1 How many children do you have? (Tick checkbox if more than 4) r2 Was your last baby born less than 1 year before? r3 Have you had any previous miscarriages? r4 Haver you had any previous difficulties in childbirth? r5 Do you have any of the following conditions? HIV, heart conditions, asthma, high blood pressure? r6 Review danger signs with the mother and remind her to look for these danger signs and go to a clinic health center immediately if she notices any of them Pain, pressure or cramping in abdomen d1 Bleeding or fluid leaking from vagina or vaginal discharge with bad odour d2 Sever nausea or vomiting d3 Fever of 38 degrees or higher d4 Severe headache or new, blurry vision problems d5 Sudden weight gain or severe selling of feet, ankles, face, or hands d6 Less movement and kicking from the baby d7 Blood in the urine or painful, burning urination d8 Diarrhea that doesn't go away d9 Last menstrual period Date of last cycle unknown? Use approximate date of last cycle date Date of last cycle unknown approx Start date of last cycle Approximate start date of last cycle up to 2 months ago 61 up to 3 months ago 91 up to 4 months ago 122 beween 5 to 6 months ago 183 beween 7 to 8 months ago 244 **The estimated delivery date is**

**Remind woman to** 1. Take Iron Folate daily 2. Attend regular ANC visits ...