Antenatal Nutrition Assessment Format

ANC Card — Maternal Nutrition (MCP Card format)

Used by dietitians, nutrition students, hospitals and health workers across India.

Fill online | Download blank PDF (free sign-up)

What the format covers

Patient Profile

  • Registration / OPD No.
  • Date of Assessment
  • Patient Name
  • Age (years)
  • Gender
  • Contact No.
  • Address
  • Referred By
  • Ward / Bed No.
  • Occupation
  • Education
  • Modified Kuppuswamy scale class
  • Medical diagnosis / chief complaint
  • Past medical & surgical history
  • Family history
  • Physical activity level (ICMR-NIN 2020)
  • Husband's Name
  • ANC Registration No.
  • MCTS / RCH ID
  • Booking Date

Obstetric History

  • Gravida (G)
  • Para (P)
  • Abortions (A)
  • Living Children (L)
  • LMP (Last Menstrual Period)
  • EDD (LMP + 280 days)
  • Gestational Age at Assessment
  • EDD by USG
  • Previous Pregnancies — table: Year, Outcome, Mode of Delivery, Birth Wt (kg), Complications
  • Current Pregnancy Complications

High-Risk Factors (MoHFW HRP)

  • Auto risk flag
  • High-risk factors present

Immunisation of Mother

  • Tetanus-diphtheria (Td) — table: Date Given, Remarks

Antenatal Ultrasound

  • Ultrasound Record — table: Date, GA by LMP, GA by USG, Placenta, AFI / Liquor, BPD/HC/AC/FL, EFW (g), Important Findings
  • Doppler Findings

Antenatal Investigations

  • Investigations — tests: Blood group & Rh, Haemoglobin, Syphilis (VDRL/RPR), HIV, Hepatitis B (HBsAg), Hepatitis C, Blood sugar / OGTT 75 g (DIPSI), TSH, Urine routine (albumin/sugar), NT / NB scan, Double / Combined test, ICT (if Rh negative), Others
  • Anaemia Classification (latest Hb, WHO)
  • Serum Ferritin (ng/mL)

General Examination

  • Height (cm)
  • Weight at Booking (kg)
  • BMI at Booking (kg/m²)
  • BMI Category (Asia-Pacific)
  • Pre-Pregnancy Weight (kg)
  • Pre-Pregnancy BMI (kg/m²)
  • BP at Booking
  • MUAC (cm)
  • Waist Circumference (cm)
  • Hip Circumference (cm)
  • Waist-Hip Ratio (WHR)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • Usual body weight (kg)
  • % weight change (%)

Obstetric Examination — ANC Visits (WHO 8 contacts)

  • Visit Record — table: Date, GA (wk), Wt (kg), BP, Oedema, Pallor, Fundal Ht (cm), Presentation, FHR, P/A Findings, Advice

Supplements & Programme

  • IFA Tablets Given (target 180) (tablets)
  • IFA Compliance
  • Calcium 500 mg BD from 14 wk
  • Albendazole 400 mg (after 1st trimester) — Date
  • Counselling Given

ANC-Specific Nutrition Assessment

  • Gestational Weight Gain to Date (kg)
  • Expected Total Weight Gain
  • Reference (guideline) — dietitian to prescribe: Additional Requirement (ICMR-NIN 2020)
  • Nausea / Vomiting
  • Pica / Unusual Cravings
  • Heartburn / Constipation

Details of Birth

  • Oxytocin Given
  • Method of Delivery
  • Indication
  • Episiotomy
  • Placenta
  • Complications

Baby

  • Date of Birth
  • Time of Birth
  • Sex
  • Birth Weight (kg)
  • Length (cm)
  • APGAR 1 min
  • APGAR 5 min
  • Anomalies
  • Breastfeeding Initiated Within 1 Hour
  • Immediate Postpartum Course & Lactation

Postnatal Care Visits

  • PNC Schedule — table: Mother BP, Hb (g/dL), Pallor, Breast / Lactation, Baby Wt (kg), Advice

Dietary Assessment

  • Diet Type
  • No. of Meals/Day
  • Appetite
  • Food Allergy / Intolerance
  • Food Aversions
  • Food Preferences
  • Water Intake (litres/day)
  • Alcohol Consumption
  • Tobacco Use
  • 24-hour dietary recall — table: Time, Meal, Food / dish, Ingredients, Household measure, Approx. quantity (g/mL)
  • Food frequency — table: Frequency, Usual portion
  • Nutritional Supplements

Nutrition-Focused Physical Examination (NFPE)

  • Muscle wasting
  • Subcutaneous fat loss
  • Oedema
  • Hair
  • Eyes
  • Mouth
  • Skin
  • Nails
  • Goitre
  • Handgrip strength (optional) (kg)

Nutrition Diagnosis & Risk Stratification

  • GLIM 2019 — phenotypic criteria
  • GLIM 2019 — etiologic criteria
  • GLIM malnutrition
  • GLIM severity (assessor confirmed)
  • Overweight/obesity status
  • PES: Problem
  • PES: Etiology (Related to)
  • PES: Signs & Symptoms (Evidenced by)

Nutrition Care Plan & Recommendations

  • Energy Requirement (clinician prescribed) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically) (kcal/day)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically) (g/day)
  • Protein Requirement (g/day)
  • Special Nutrient Focus
  • Dietary Advice / Modifications
  • Sample Meal Plan Given?
  • Next Follow-Up Date
  • Counselling Notes
  • Monitoring & Evaluation — table: Indicator, Baseline, Target, Review date, Outcome

Diet Prescription (filled by dietitian)

  • Prescribed energy (kcal/day)
  • Prescribed protein (g/day)
  • Prescribed fluid (mL/day)
  • Diet type / consistency
  • Restrictions
  • Meal plan — table: Time, Food / dish, Quantity (household measure)
  • Foods to include
  • Foods to avoid
  • Prescribed by (name, reg. no.)

Signature

  • Dietitian Name & Signature

Automatic scores in this form

  • EDD (LMP + 280 days)
  • Gestational Age at Assessment
  • Auto risk flag
  • Anaemia Classification (latest Hb, WHO)
  • BMI at Booking
  • BMI Category (Asia-Pacific)
  • Pre-Pregnancy BMI
  • Waist-Hip Ratio (WHR)
  • Waist risk (Asian cut-off)
  • Waist-to-height ratio
  • % weight change
  • Gestational Weight Gain to Date
  • Reference (guideline) — dietitian to prescribe: Additional Requirement (ICMR-NIN 2020)
  • GLIM malnutrition
  • Reference (guideline) — dietitian to prescribe: Energy (ICMR-NIN 2020, healthy-adult baseline only; indicative — adjust clinically)
  • Reference (guideline) — dietitian to prescribe: Protein (ICMR-NIN 2020 adult 0.83 g/kg; healthy-adult baseline only, indicative — adjust clinically)

All calculated values are indicative — clinical judgement required.

Standards & references

  • WHO ANC Recommendations 2016
  • MoHFW Mother & Child Protection (MCP) Card
  • ICMR-NIN Nutrient Requirements for Indians 2020
  • MoHFW Anaemia Mukt Bharat
  • ICMR-NIN 2020
  • GLIM 2019
  • Nutrition Care Process (ADIME)

Frequently asked questions

What is included in the Antenatal Nutrition Assessment format?

The format has 19 sections: Patient Profile; Obstetric History; High-Risk Factors (MoHFW HRP); Immunisation of Mother; Antenatal Ultrasound; Antenatal Investigations; General Examination; Obstetric Examination — ANC Visits (WHO 8 contacts); Supplements & Programme; ANC-Specific Nutrition Assessment; Details of Birth; Baby; Postnatal Care Visits; Dietary Assessment; Nutrition-Focused Physical Examination (NFPE); Nutrition Diagnosis & Risk Stratification; Nutrition Care Plan & Recommendations; Diet Prescription (filled by dietitian); Signature. It also calculates 16 values automatically, such as EDD (LMP + 280 days), Gestational Age at Assessment, Auto risk flag.

Which guidelines does the Antenatal Nutrition Assessment follow?

It follows WHO ANC Recommendations 2016, MoHFW Mother & Child Protection (MCP) Card, ICMR-NIN Nutrient Requirements for Indians 2020, MoHFW Anaemia Mukt Bharat, ICMR-NIN 2020, GLIM 2019, Nutrition Care Process (ADIME). All calculated values are indicative — clinical judgement is required.

Can I download the Antenatal Nutrition Assessment as a PDF?

Yes. After a free sign-up you can fill the form online and download both blank and filled A4 PDFs, and save private case sheets for your patients.

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