General Information
Name*
Occupation
Date of Birth*
Address*
Cell Phone*
Home Phone*
Work Phone*
Profile
Significant Other/ Partner/ Father of Baby
Occupation
Was This Pregnancy Planned*
Yes
No
Are you and the baby's father happy about this pregnancy?*
Yes
No
Marital Status*
Single
Partner
Married
Divorced
Other
List Other People Living With You And Their Relationship To You:
Social History
Have you ever or are you now being sexually or physically abused?*
Yes
No
Do you feel unsafe at home?
Yes
No
Have you ever had professional counseling?*
Yes
No
Emotionally or verbally abused?*
Yes
No
If you answered YES to any of the above, provide details
Menstrual History
What is the date of the first day of your last menstrual period?
Are your menstrual cycles regular?*
Yes
No
How many days are usually between the first day of one period and the first day of the next period?
What is the date of your first pregnancy test?
Any negative pregnancy tests after your last period? When?
Yes
No
Was this pregnancy conceived while using birth control?
Yes
No
Do you have a history of infertility?
Yes
No
Was this pregnancy achieved with any fertility medication or procedures?*
If yes, please check all that apply: Meds
IUI
IVF
Obstetric History
# of Pregnancies (including current)
# of Deliveries
# of Abortions
# of Miscarriages
# of Ectopics
# of Stillbirths
# of Living children
# of Adopted children
Delivery History
Delivery #1
Name
Date Of Birth
Sex
Select one
Female
Male
Delivery Type
C-Section
Forceps
Vacuum
VBAC
Vaginal
Weeks
Baby's Weight
Hospital
MD
Pain Management
Delivery #2
Name
Date Of Birth
Sex
Select one
Female
Male
Delivery Type
C-Section
Forceps
Vacuum
VBAC
Vaginal
Weeks
Baby's Weight
Hospital
MD
Pain Management
Delivery #3
Name
Date Of Birth
Sex
Select one
Female
Male
Delivery Type
C-Section
Forceps
Vacuum
VBAC
Vaginal
Weeks
Baby's Weight
Hospital
MD
Pain Management
Delivery #4
Name
Date Of Birth
Sex
Select one
Female
Male
Delivery Type
C-Section
Forceps
Vacuum
VBAC
Vaginal
Weeks
Baby's Weight
Hospital
MD
Pain Management
Delivery #5
Name
Date Of Birth
Sex
Select one
Female
Male
Delivery Type
C-Section
Forceps
Vacuum
VBAC
Vaginal
Weeks
Baby's Weight
Hospital
MD
Pain Management
Delivery #6
Name
Date Of Birth
Sex
Select one
Female
Male
Delivery Type
C-Section
Forceps
Vacuum
VBAC
Vaginal
Weeks
Baby's Weight
Hospital
MD
Pain Management
Have you had any of the following complications with any previous pregnancies:
Incompetent cervix or cerclage*
Yes
No
Post-partum hemorrhage (heavy bleeding)*
Yes
No
Diabetes*
Yes
No
Labor or rupture of membranes more than 3 weeks early*
Yes
No
Baby that weighed less than 6 lbs or more than 9 lbs*
Yes
No
High blood pressure in pregnancy*
Yes
No
Death of an infant*
Yes
No
Placenta problems*
Yes
No
Too much or too little amniotic fluid*
Yes
No
Twins or more*
Yes
No
Post-partum depression*
Yes
No
Uterine rupture*
Yes
No
Any Other Complications Not Listed?
Your Medical History
Diabetes*
Yes
No
High blood pressure*
Yes
No
Heart conditions*
Yes
No
Thyroid conditions*
Yes
No
Kidney problems*
Yes
No
Neurologic diseases*
Yes
No
Seizures*
Yes
No
Depression*
Yes
No
Anxiety*
Yes
No
Suicidal thoughts or attempts*
Yes
No
High cholesterol*
Yes
No
Vaginal infections*
Yes
No
Hepatitis/Liver disease*
Yes
No
Bleeding disorder*
Yes
No
Clotting disorder*
Yes
No
Varicose veins*
Yes
No
Asthma*
Yes
No
Rheumatoid arthritis*
Yes
No
Lupus*
Yes
No
Migraines*
Yes
No
Bladder infections*
Yes
No
Anemia*
Yes
No
Seasonal/environmental allergies*
Yes
No
Any cancers*
Yes
No
Your Infection History
Chicken pox*
Yes
No
Chlamydia*
Yes
No
Cytomegalovirus*
Yes
No
Gonorrhea*
Yes
No
Hepatitis B exposure*
Yes
No
Hepatitis B vaccinated*
Yes
No
HIV exposure*
Yes
No
HPV*
Yes
No
Partner history of genital herpes*
Yes
No
Personal history of genital herpes*
Yes
No
Parvovirus*
Yes
No
Syphilis*
Yes
No
TB exposure*
Yes
No
Toxoplasmosis*
Yes
No
Surgeries and Approximate Dates
Immediate Family Members (Your Parents, Sibling(s), Children) Who Have:
Diabetes
High Blood Pressure
Heart Disease
High Cholesterol
Breast/Ovarian cancer
Dementia/Alzheimers
Malignant hyperthermia
Bleeding/Clotting disorders
Thyroid disease
Alcoholism/Drug abuse
Depression/Suicide
Other cancers
Genetic History – Please Answer All Questions
Are You Or The Baby's Father Members Of Any Of The Following Ethnic Or Social Groups:
Italian
Greek
Mediterranean
Asian
Ashkenazi Jewish
Cajun
French Canadian
African
Do Any Of Your Relatives Or The Baby's Father's Relatives Have:
Thalessemia*
Yes
No
Neural tube defects, Spina Bifida, Anencephaly*
Yes
No
Congenital heart defect*
Yes
No
Down Syndrome*
Yes
No
Tay-Sachs*
Yes
No
Sickle cell disease or trait*
Yes
No
Hemophilia or other blood disorders*
Yes
No
Muscular Dystrophy*
Yes
No
Cystic Fibrosis*
Yes
No
Huntington's Chorea*
Yes
No
Mental retardation/autism*
Yes
No
Tested For Fragile X*
Yes
No
Maternal relatives have metabolic disorder*
Yes
No
Please specify:
Other birth defects:
Will you be 35 years old or older when baby is due*
Yes
No
Health Maintenance
Date Of Last Pap
Within Last Year
1 – 2 Years
> 2 Years
Never
Result
Any History of abnormal pap tests?*
Yes
No
Any History of LEEP procedures?*
Yes
No
Last Flu Vaccine
Patient Full Name Signature
Please click checkbox to affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of your knowledge and belief.
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