Download Pregnancy Questionnaire

Pregnancy Questionnaire
Today’s Date: ________/________/________
First Name: _______________________________ Middle Initial: _______ Last Name: ___________________________
Primary Phone Number: ___________________ D.O.B: ________/________/________ Age: ___________
Ethnicity: ________________________________
Primary Language: ________________________________
OB History
When was the first day of your last period ________/________/________
Don’t know
Were you on birth control at the time of conception? Yes No
Don‘t Know
Haw many TOTAL pregnancies have you had, including this one? ____________________________________________
What is your occupation? ____________________________________________________________________________
Do you come in contact with hazardous chemicals or do any heavy lifting (>20) while on the job?
Yes No
If yes, please explain: _______________________________________________________________________________
Marital Status: Married Single Domestic Partner Divorced Widowed
Height: __________________________________________
Pre-Pregnancy Weight: _________________________
Name of the Baby’s Second Parent: ___________________________________________________________________
Second Parent Contact Phone Number: ________________________________________________________________
Gyn History
First Day of Last Menstrual Period: ________/________/________ Age of First Period: ________/________/________
How often do you have a period: ___________________ How many days does your period last: ______________
Date of your last Pap smear: __________________________
Have you ever had an abnormal Pap smear? : Yes No If yes, When? _____________________________
Treated with:
Follow-up
Pap smear
Colposcopy
LEEP
Are you currently sexually active? : Yes No
How many partners have you been with? : None
One 2-5 More than 5
Have you ever had a sexually transmitted disease? : Yes No
Method of birth control: __________________________________
Have you ever used Gardasil? Yes No
Personal Medical History
This section of questions pertains to YOUR medical history. Please indicate if YOU have had any of the following.
High Blood Pressure:
Heart Disease:
Yes
Yes
No
No
Tobacco Use:
Yes
If Yes, How many packs a day? __________
No
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Autoimmune Disorder:
Kidney Disease/ Stone/ UTI
Neurologic Disorder/Seizures:
Depression/Postpartum
Depression
History of Mental Disorder?
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
If yes, what disorder? Are you currently under
treatment? : _____________________________________
Anesthetic Complications:
Hepatitis/Liver Disease:
Thyroid Dysfunction:
Uterine Anomaly/DES Exposure:
Infertility:
Diabetes:
Alcohol/Drug Use:
Yes No
Yes No
Yes No
YesNo
Yes No
Yes No
Yes No
Pulmonary Disorder (TB/Asthma):
Yes No
Seasonal Allergies:
Yes No
Drug/ Latex Allergy:
Yes No
If yes, please list allergy and reaction: ______________
_____________________________________________
Breast Disorder/Surgery:
Yes No
Gynecologic Surgery:
Yes No
If yes, what complication? ______________________
____________________________________________
Varicosities/Phlebitis:
Yes No
History of Abnormal Pap:
Yes  No
Sexual Abuse/Domestic Violence
Yes No
History of Blood Transfusion:
Yes No
*Please List all the medications you are currently taking, including any supplements or herbal preparations*
Medications
Dosage/Frequency
Please list any Surgeries you have had along with surgery date
Surgery
Date
*Please list any previous Hospitalizations and approximate date:
Reason for Hospitalization
Date
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Immediate Family Medical History
The following section of questions pertains to YOUR immediate family, (Parent, Grandparent and / or Siblings).
Do you have a FAMILY history of?
Heart Disease:
Yes No
High Cholesterol:
Yes No
High Blood Pressure:
Yes No
Cancer:
Yes No
If Yes, list who and what type: ____________________
_____________________________________________
Thyroid Problems:
Hepatitis:
AIDS or HIV:
Diabetes:
Yes
Yes
Yes
Yes
No
No
No
No
Genetics History
The Following section of questions pertains to YOU, the BABY’S FATHER, or EITHER OF YOUR FAMILIES.
Is there any history of:
Thalassemia
Yes
No
(Italian, Greek, Mediterranean, or Asian Descendent)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If Yes, was the person tested for fragile X? Yes No
Other inherited Genetic or
Chromosomal Disorder
Yes No
Recurrent pregnancy loss or stillbirth? Yes No
Patient or Father of Baby had other child with birth defects not listed? Yes No
If you answered YES to any of the above questions, please explain: ________________________________________________
Neural Tube Defect
Congenital Heart Disease
Down Syndrome
Tay-Sachs Disorder
Sickle Cell Disease or Trait
Hemophilia or other Blood
Muscular Dystrophy Disorder
Cystic Fibrosis
Mental Retardation/Autism
Infection History
Do you live with someone diagnosed with TB or have you been exposed to TB?
Yes
No
Do you or your partner have history of herpes? (Oral or Genital)
Yes
No
Have you had a rash or viral illness since your last period?
Yes
No
Have you had Hepatitis B or C exposure?
Yes
No
Have you had an STD in the past year?
Yes
No
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Risks
Uterine or Cervical Malformation
Suspect Pelvis (not large enough to accommodate baby)
Rh Negative (Negative Blood Type)
Anemia
Failure to Gain Weight (< 20 lbs.)
Excessive Weight Gain (> 40 lbs.)
Abnormal Fetal Presentation (Breech/Transverse Lie)
Post-Term Delivery (> 40 weeks)
Acute Pyelonephritis
Sexually Transmitted Disease
Alcohol use with Pregnancy
Diabetes with Pregnancy
Hypertension (High Blood Pressure)
Thrombophlebitis
Herpes (Oral or Genital)
Rh Sensitization
Uterine Bleeding
Polyhydramnios (High Amniotic Fluid)
Oligohydramnios (Low Amniotic Fluid)
Mild Pre-Eclampsia
Severe Pre-Eclampsia
Fetal Growth Retardation
Premature Rupture of Membranes
Multiple Pregnancy
Alcohol or Drug Abuse
Did any of your parents have a problem with alcohol or other drug use?
Does your partner have a problem with alcohol or drug use?
In the past, have you had difficulties in your life because of alcohol or
other drugs, including prescription medication?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
In the past month have you consumed any alcohol or used other drugs?
Yes
No
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*Please give detailed information about each of your
previous pregnancies even if it ended in
miscarriage or abortion.*
Date of
Delivery
Weeks
Of
Gestation
Length
of
Labor
Birthweight
Sex
(M/F)
Vaginal/ Epidural
C-Sect
Place of
Delivery
Preterm
Labor
(<37
Wks)
Complications?
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