Download Prenatal Packet - Toms River OB/GYN Associates, PA

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TOMS RIVER OBSTETRICS & GYNECOLOGY ASSOCIATES
79 ROUTE 37 WEST, SUITE 101
TOMS RIVER, NEW JERSEY 08755
Tel 732 244 9444
Fax 732 244 9468
INFORMATION FOR EXPECTANT PARENTS
PATIENT NAME_______________________________________________________________________________Date_____/_____/_____
Welcome to our office! The physicians at Toms River Ob-Gyn practice medicine as a team with a rotating on-call schedule.
Your prenatal visits will be arranged so that you will meet all the doctors and they will be able to become acquainted with you as well.
If you need to contact the office, please call during our usual business hours Monday to Friday 9 a.m. to 4 p.m. at (732) 2449444. If you have an obstetrical emergency and are less than twenty (20) weeks pregnant, then go to the nearest emergency room. If
you are twenty (20) or more weeks pregnant and are in labor or have an emergency, then go to the hospital’s labor and delivery suite.
Community Medical Center’s labor and delivery is located on the fifth (5th) floor of the hospital.
Toms River Ob-Gyn Associates endeavors to provide emergency and obstetrical services 24 hours a day, seven days a week,
to our patients. Although most of this coverage is provided by the practitioners at Toms River Ob-Gyn Associates, it is occasionally
necessary to have other healthcare providers outside of this practice be available for emergencies.
Usually, your routine prenatal appointments will be arranged at approximately four-week intervals for the first seven months
of your pregnancy. After that, you may be seen every two weeks and during the last month, at least every week.
You may need to see the doctor during your pregnancy for problems outside of your routine prenatal care. You may be
responsible for your co-pay in these instances.
Our patients are delivered at Community Medical Center, Toms River, NJ. You should contact the hospital for their fees and
charges, and also check with your insurance company for their coverage. Certain medical specialists on staff at the hospital, such as
neonatologists (newborn pediatric specialists) or anesthesiologists, may be needed to care for either yourself or your newborn infant
during your hospital stay. Some of these specialists may not participate in your insurance plan, and you may be responsible for their
entire bill. At present, the hospital has contracted with a group of neonatologists, ON-SITE, who are pediatricians who work
specifically under contract with the hospital. These doctors may be present at your delivery, whether by Cesarean or vaginal. It is
understood that these doctors will accept your insurance and will not balance bill you. Any questions regarding this should be
discussed with the hospital finance department (Tel 732 557 2550). Toms River Ob-Gyn Associates accepts no responsibility for any
bills incurred by doctors, hospitals, laboratories, x-ray facilities or other medical providers outside of its practice.
It is recommended that you take a tour of the maternal-child facility at Community Medical Center at some point during
your pregnancy in order to become acquainted. Please contact the hospital at 732 557 8034 for more information on tours. Preregistration for the hospital can be done over the telephone by calling the Financial Clearance Center at Community Medical Center at
732 557-2550 or by obtaining a pre-admission form from out office and sending it to the hospital admitting office.
Please note that our doctors perform tubal ligations at the time of delivery only for women undergoing Cesarean sections. All
other patients who wish to have surgical sterilization are asked to discuss with their doctor when the best time for sterilization would
be.
Routine services provided by Toms River Ob-Gyn Associates are listed below. For a listing of our current fees, please
contact the billing office.
Routine care during office hours, during pregnancy
Uncomplicated delivery
Postpartum care in the hospital following delivery
Postpartum visits in the office, 6 weeks after vaginal delivery and
2 weeks and 6 weeks after Cesarean section
Services not included in our obstetrical fees:
Laboratory work and Pap smears
Medications
Special tests and procedures in office or hospital
Other surgeries
Non-routine visits in the office
Medical problems not related to pregnancy
Emergency room visits
Anesthesia for Labor & Delivery
Newborns care, including pediatrician and neonatologist
Community Medical Center charges
expectant parents letter/revised june 18, 2011
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We will submit claim forms to the insurance companies that we participate with for routine prenatal,delivery, and postpartum
care that we provide. If any other services are provided, the claims will be submitted as the charges are incurred.
If you do not have insurance, we will require a monetary deposit, starting with your initial care. The remainder of the fee has
to be paid in full prior to your estimated date of delivery. If you leave our care prior to your delivery, you will be charged for your
office visits and any other care provided by us up until that time. Please feel free to contact our office about any questions you may
have regarding our fees.
Other responsibilities:
Please note that most insurance companies require notification for scheduled or emergency hospital admissions. It is your
responsibility to notify your insurance company directly. Failure to do so may result in decreased benefits from your insurance
company, and possibly cause increased financial responsibility on your part.
It is customary to have a two-day stay following a vaginal delivery, and a four-day stay following a Cesarean section. Please
contact your insurance company to determine the number of days allowed under your health plan. Insurance companies vary regarding
notification of delivery. It is your responsibility to supply them with this information. If Home Health Care is needed after a delivery,
please check with your insurance plan to see if it is a covered benefit.
Disability:
Disability tends to vary for each individual pregnancy. Many women prefer to work up until their due date. Please obtain
your disability form from your place of work and bring it to the office to be completed. If you require special disability consideration,
please discuss this with the doctor.
Our ultimate goal is to provide you with good obstetrical care, and the delivery of a healthy newborn. Please let us know if there is
anything more we can do for you, and always feel free to ask questions.
I certify that I have read or had read to me the contents of this form; I have had the opportunity to
ask any questions which I had and all of my questions have been answered. I have also filled out all of
the pre-natal forms given to me (pages 1-10) to the best of my knowledge and received a copy of all of
them.
SIGNATURE OF PATIENT_____________________________________________DATE_____/_____/_____
PRINTED NAME OF PATIENT__________________________________________DOB_____/_____/_____
PHYSICIAN__________________________________________________________Witness______________
expectant parents letter/revised june 18, 2011
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TOMS RIVER OB-GYN ASSOCIATES
INFORMATION FOR THE SECOND HALF OF PREGNANCY
PATIENT NAME________________________________________________________________Date_____/_____/_____
1. Toms River Ob-Gyn Associates endeavors to provide emergency and obstetrical services 24 hours a day, seven days
a week, to our patients. Although most of this coverage is provided by the practitioners at Toms River Ob–Gyn
Associates, it is occasionally necessary to have other healthcare providers outside of this practice be available for
emergencies.
2. If you are twenty (20) or more weeks pregnant and are in labor or have an emergency, then go to the hospital’s labor and
delivery suite. Community Medical Center’s labor and delivery is located on the fifth floor of the hospital. It is
recommended that you take a tour of the facility beforehand to become acquainted. Please contact the hospital at 732 557
8034 for more information on tours. Pre-registration for the hospital can be done over the telephone by calling the
Financial Clearance Center at Community Medical Center at 732 557-2550.
3. In order to help your doctors evaluate and assure the well-being of your baby, it is important that you monitor your baby’s
movements. Your baby will usually start to move (flutters) between the 16th and 20th week of your pregnancy (around the
4th month). Movement tells you that your baby is healthy and growing. A simple way to monitor your baby’s activity is
by the “kick count.” When the baby is normally active, say for example, after a meal, count the number of times that the
baby moves in a one hour period of time. Usually, there may be 5 to10 or more movements or kicks during that time.
Learn YOUR baby’s typical “times of movement and sleep time.” Movement should continue right up to the time of
delivery. If your baby’s movements suddenly change or stop, call your doctor right away! REMEMBER, not one day
should pass without you feeling your baby move.
4. Please observe the following guidelines
 Sexual relations should be discontinued during the pregnancy if you have had any bleeding, pain,
or cramping, or the doctor has advised you to abstain.
 Do not travel further than one hour away from the hospital during the last month of pregnancy.
5. You need to be evaluated
 If you suspect that you are starting labor
First baby: contractions approximately every 5 minutes for 1 to 2 hours
Second or more babies: contractions approximately every 10 minutes for 1 hour
 If you suspect that your membranes have ruptured and you are leaking fluid
 If you are having vaginal bleeding like a period
 If you do not feel your baby moving as much as usual
6. You, or your baby, may require the in-hospital services of an anesthesiologist or neonatologist. These specialists might
not participate in your insurance plan and you may be directly responsible for their fees. If you have any questions
concerning this, then you should contact the hospital for further information.
7. A vaginal culture for Group B Strep bacteria may be performed by your physician at approximately 36 weeks gestation.
This bacteria is usually harmless but may cause an infection of mother or infant a the time of labor. Any pregnant woman
diagnosed with Group B Strep may need antibiotics at the time of delivery. It is important that you are aware of the results
so that you may inform the nursing staff on Labor and Delivery at the time that you go to the hospital.
8. Visiting Hours: A maximum of three designated support persons are allowed by the hospital for visitation on Labor and
Delivery. For the Women’s Health Unit on floors 5E and 5F visiting hours are from Noon-8 pm daily: one person may
stay overnight in the patient’s room at her request; Siblings and children 14 years and older may visit from noon to 8 pm.
Daily.
instructions for pregnancy/revised june 18,2011
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TOMS RIVER OB-GYN ASSOCIATES
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OBSTETRICAL FINANCIAL POLICY
PATIENT NAME________________________________________________________________Date_____/_____/_____

In consideration of services rendered and to be rendered by Toms River Ob-Gyn Associates, its physicians
and employees, I hereby authorize my health care insurer(s) to pay Toms River Ob-Gyn Associates P.A.
directly for covered services.

Obstetric patients may incur fees for services rendered during their pregnancy that may not be covered
under global payments by their insurance companies. Ultrasounds or sonograms, non-stress tests, biophysical
profiles, certain laboratory tests and hospital visits, in-patient and out-patient problem visits related or
unrelated to pregnancy and other services outside of general obstetrical appointments with your physician may
be billed separately. You may be financially responsible for such services.

I accept sole responsibility for all charges incurred as a result of services rendered, and agree to pay
amounts not covered by my insurers, including Medicare if applicable. These amounts normally are due and
payable at the time that services are rendered.

If my insurance requires a co-pay, I agree to submit this fee to Toms River Ob-Gyn Associates at the time
of my visit. For your convenience, our office accepts Visa, Mastercard, checks and cash.

Any balances on my account older than thirty (30) days will be subject to an additional interest fee of one
and one-half (1 ½) per cent (%) per month. All balances that reach ninety (90) days past due will be sent to a
collection agency unless other arrangements have been made with this office. Should your account be sent to
a collection agency, you will be financially responsible for all collection and legal fees that our office incurs
through the process utilized to collect the outstanding delinquent balance.

If you have medical insurance, as a courtesy, we will file your insurance claims for you. However, all
charges are your responsibility from the date that services were rendered. Therefore, you should be fully
aware of the benefits provided by your insurance carrier. We participate in many insurance plans but it is your
responsibility to know if Toms River Ob-Gyn Associates participates in your plan.

Payment in full of any past due balance is expected prior to receiving services in our office. If you have any
questions regarding the above please contact our billing office.

I have read and fully understand the financial policy of Toms River Ob-Gyn Associates and agree to its
terms. I further understand that the financial policy of Toms River Ob-Gyn Associates may be changed or
amended at any time without prior notification to the patient.
I certify that I have read or had read to me the contents of this form; I have had the opportunity to ask any questions
which I had and all of my questions have been answered.
SIGNATURE OF PATIENT_____________________________________________DATE_____/_____/_____
PRINTED NAME OF PATIENT_________________________________________DOB_____/_____/_____
PHYSICIAN_________________________________________________________Witness_______________
obstetrical financial policy/revised june 18, 2011
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TOMS RIVER OB-GYN ASSOCIATES
PERINATOLOGISTS
PATIENT NAME________________________________________________________________Date_____/_____/_____
The doctors at Toms River OB-GYN Associates request that all pregnant patients under their care receive genetic counseling and
evaluation of the mother and baby by a perinatologist. This is a doctor who is especially trained to detect problems during the
pregnancy and to care for problem pregnancies. These doctors employ a variety of techniques that may be useful in determining that
you have a healthy baby and pregnancy. Perinatologists provide a variety of services for the pregnant patient which may include, but
not be limited to, the items listed below. I should be noted that the doctors at Toms River Ob-Gyn do not do genetic counseling,
anatomy scans that check for fetal abnormalities, integrated screening, CVS testing or amniocentesis. To have any of these tests or
procedures, the patient must discuss them with a perinatologist. A list of local perinatologists ,for your convenience, has been
provided. The doctors at Toms River do not endorse any particular perinatologist and you should decide yourself which one you will
make an appointment with.
 Consultation: a discussion of your pregnancy, possible risk factors, and testing that may be needed.
 Level II Sonogram: This is an ultrasound of the baby that evaluates the anatomy of the fetus. The test is usually performed
around 18 to 22 weeks pregnancy. Fetal structures evaluated include the heart, brain, kidneys, spine, intestines, and other
parts of the body
 Integrated screening: A blood test and early ultrasound to check the fat pad on the back of the baby’s neck is performed at
ten to fourteen weeks pregnancy. Combined with another blood test at around 16 weeks pregnancy and with a Level II
ultrasound at 18 to 22 weeks pregnancy, the integrated screening will evaluate for Down’s syndrome and other disorders of
the fetus. Integrated screening is recommended for all of our pregnant patients. It is important that you schedule an
appointment as soon as you possibly can with the perinatologist so that you may take advantage of this important test.
 CVS testing: This is a biopsy taken of placental tissue inside the uterus to screen for Down’s syndrome and other
chromosomal disorders.
 Amniocentesis: Fluid surrounding the fetus is tested for chromosome defects including Down’s syndrome. This test is
usually done between 16 and 20 weeks
Dr. Charles Hux
2130 Highway 35, Bldg A, Suite 123
Seagirt, N.J. 08750
Tel 732 449-9900
Premier Perinatal
Dr.Carlos Fernandez
1416 Hooper Avenue, Suite 1
Toms River, N.J. 08753
Tel 732 736-0300
Fax 732 736-9600
Dr. Joseph Canterino
Dr. Paul Matta
Dr. Michael Muench
Dr. Miriam Modestin
Dr. Carlos Benito
Jersey Shore Perinatal Institute
1944 State Highway 33, Suite 203
Neptune, N.J. 07753
732 776 4755
Obstetric Medicine Service
Dr. Michael Carson
Brandywine Commons, Route 33
Neptune, NJ 07753
732 897 3990
*evaluates medical problems in pregnancy
Dr. Nisha Malik
Dr. David Wallace
Dr. David Gonzalez
Dr. William MacMillan
Dr. Carl Nath
Monmouth Medical Group
73 South Bath Avenue
Long Branch, N.J. 07740
732 870-3600 Fax 732 870-0119
Lakewood Office
1 Route 70 West
Lakewood, N.J. 08701
732 901-0211 Fax 732 901-0199
I have read the above information and have been counseled by my doctor concerning the tests that are available by perinatologists
to evaluate my pregnancy and the health of my fetus or unborn child. I understand that to be counseled for or to have these tests done
I must make an appointment with a perinatologist myself. I understand that the perinatologist will discuss genetic counseling,
integrated screening, Level II anatomy ultrasound scanning, amniocentesis, and CVS testing as it may apply to me. As your doctors
caring for your pregnancy, we recommend strongly that all of our pregnant patients make an appointment to see a perinatologist.
I certify that I have read or had read to me the contents of this form; I have had the opportunity to ask any questions
which I had and all of my questions have been answered.
SIGNATURE OF PATIENT___________________________________________________________DATE_____/_____/_____
PRINTED NAME OF PATIENT________________________________________________________DOB_____/_____/_____
PHYSICIAN_______________________________________________________________________Witness______________
Note: This is only a partial list of doctors who specialize in perinatology or high risk obstetrics. There are many other doctors in this field and you may want to use a
doctor not found on this list. The addresses and telephone numbers on this list may change so please check the telephone directory to confirm them before contacting
the doctor. Please call your insurance company to see if the doctor that you have selected participates in your insurance. Make an appointment with the doctor that you
have selected. If you require a referral by your insurance company, please notify our office after you have made the appointment so that we can obtain the referral .
perinatologist list/revised june 18, 2011
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TOMS RIVER OB-GYN ASSOCIATES
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PATIENT NAME_______________________________________________DOB_____/_____/_____
CONSENT FOR HIV BLOOD TEST
I have been informed by the doctor that my blood should be tested in order to detect whether or not I have antibodies in my
blood to the Human Immunodeficiency Virus. The reason for the test is to see if I am positive for HIV during my pregnancy. A
positive HIV test will mean that my baby and I will need, during my pregnancy, special care and treatment that may decrease the
chances of my baby becoming infected.
The test results, in some cases, may indicate that a person has the antibodies to the HIV virus, when the person actually does
not (a false positive test). The test may also fail to detect that a person has antibodies to the virus, when the person actually does ( a
false negative test). A positive HIV test does not mean that I have AIDS (Acquired Immune Deficiency Syndrome), and that in order
to diagnose AIDS, other tests would have to be used, in addition to this test.
I have been informed that if I have any questions regarding the nature of the blood test, the significance of its results, and the
possible effects of a record of a positive test, I may ask those questions before deciding as to whether or not to submit to the blood test.
Further, I have been advised as to the availability of anonymous testing.
CONSENT FOR OBSTETRICAL ULTRASOUND
You will be advised to have one or more ultrasound tests during your pregnancy. In this test, sound waves are sent through
your abdomen (belly) and are reflected back to form pictures. This test is not a treatment for any condition, but is done for the purpose
of diagnosis or testing only. Information from the test may help the doctor manage your pregnancy more successfully. Obstetrical
ultrasound is commonly used to estimate the size and maturity of the baby as well as the possibility of more than one baby, or an
abnormality being present. It is possible that a defect or problem may be falsely reported or not detected at all by obstetrical
ultrasound. Because of these facts, your doctor can make no guarantee as to the accuracy of the test.
Obstetrical ultrasound is considered to be a reasonably accurate method for diagnosis and an aid to the management of
pregnancy. Although obstetrical ultrasound has no known complications, the long term effect of ultrasound on tissues of the mother or
baby is unknown. There may be alternatives to this procedure available to you. However, these alternative methods carry their own
risks of complications and have varying degrees of success. Therefore, in those women in whom obstetrical ultrasound is indicated,
this test may provide the best chance of successful diagnosis with the lowest risk of complications.
CONSENT FOR AFP TETRA SCREENING
You will be offered a blood test, when you are approximately 16 (sixteen) weeks pregnant, known as an Alpha-Fetoprotein
Tetra Screen. This test measures four different chemicals in your body. The amount of these chemicals, plus your age, weight, and
weeks of pregnancy, are then calculated to give a number, or AFP Tetra result. If the result is out of the normal range, this may
indicate that your baby may be at a higher risk of having a chromosome abnormality, such as Down’s syndrome, or of having a spinal
defect. In addition, a result out of the normal range may indicate that your pregnancy is at higher risk for other complications.
An AFP Tetra result may be out of the normal range, and yet nothing at all be wrong with your baby. On the other hand, an
AFP Tetra result may be within normal range, but your baby may still have some abnormality. In other words, an AFP Tetra result
within the normal range is still no guarantee that there is no abnormality of the baby. The AFP Tetra screen test is used mainly to help
the doctor identify which mothers or babies are at higher risk. If your AFP Tetra test is out of the normal range, or if you are 35 years
old or older at your estimated date of delivery, or for other indications, you will be offered further testing to determine if any
abnormalities may actually be present.
By not having the AFP Tetra test, your doctor may not be able to identify if you are at increased risk for certain
abnormalities. This could result in missing some abnormality that could adversely affect your pregnancy.
 I consent for HIV testing:
 I decline HIV testing
 I consent for ultrasound:
 I decline ultrasound testing
 I consent for AFP tetra testing:  I decline AFP tetra testing
I certify that I have read or had read to me the contents of this form; I have had the opportunity to
ask any questions which I had and all of my questions have been answered.
SIGNATURE OF PATIENT_____________________________________________DATE_____/_____/_____
PRINTED NAME OF PATIENT_________________________________________DOB_____/_____/_____
PHYSICIAN_________________________________________________________Witness_______________
hiv/sono/afp consent/revised june 18, 2011
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TOMS RIVER OB-GYN ASSOCIATES
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UMBILICAL CORD BLOOD COLLECTION
PATIENT INFORMATION
You may wish to have the umbilical cord blood of your baby collected for banking and potential future use. If you are interested in
this option, a list of some of the cord blood banks is listed below. This list is not a complete one and there may be other banks
available that you may wish to contact.
Alpha Cord
California Cryobank
Cord Blood Registry
Cor-Cell
Cryo-Cell
Cryobanks
Lifebank
New England Cord Blood Bank
ViaCord
866 396-7283
800 400-3430
888 267-3256
888 326-7235
800 786-7235
800 869-8608
877 543-3226
888 7002673
866 668-4889
If you have decided to have your baby’s cord blood collected, and have arranged this through a cord blood bank, please advise your
doctor. You will be responsible for bringing the cord blood collection kit to the hospital when you are going to deliver. Your
obstetrician will have to use the kit to collect the umbilical cord blood at the time of delivery.
Although your obstetrician will attempt to collect umbilical cord blood for you at the time of the delivery, there can be no
guarantee that blood may be obtained. Furthermore, Toms River Ob-Gyn Associates can make no guarantees and shall be held
blameless regarding the collection, storage, transport, and any future uses or claims regarding the cord blood.
Toms River Ob-Gyn Associates requires a collection fee of $200.00 (Two Hundred Dollars) for this service. Full payment of this
fee is required three months prior to the anticipated date of delivery.
I certify that I have read or had read to me the contents of this form; I have had the opportunity to ask any questions
which I had and all of my questions have been answered.
SIGNATURE OF PATIENT____________________________________________________DATE_____/_____/_____
PRINTED NAME OF PATIENT_________________________________________________DOB_____/_____/_____
PHYSICIAN________________________________________________________________Witness______________
cord blood collection information/revised june 18, 2011
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TOMS RIVER OB-GYN ASSOCIATES
PRE NATAL QUESTIONNAIRE
Patient Name_________________________________________
DATE_____/_____/_____
DO YOU HAVE A HISTORY OF ANY OF THE PROBLEMS OR DISORDERS LISTED
BELOW?
A. MEDICAL HISTORY
1.
Diabetes
2.
High Blood Pressure
3.
Heart disease
4.
Autoimmune diseases such as Lupus, Scleroderma, Rheumatoid arthritis
5.
Kidney disease?
6.
Neurological disorders, Epilepsy or Seizures
7.
Psychiatric disorders
8.
Depression or post-partum depression
9.
Hepatitis or liver disease
10. Varicose veins, blood clots, phlebitis
11. Thyroid disorders
12. Trauma or violence
13. History of blood transfusions
14. Tobacco use
15. Alcoholism or drinking disorders
16. Illicit drug use or use of recreational drugs
17. Rh disease or sensitization
18. Pulmonary disease such as Asthma or Tuberculosis
19. Seasonal allergies
20. Allergies to Drugs or to Latex
21. Breast problems or surgery
22. Gynecological surgery
23. Operations and Hospitalizations: state the year and reason
24. Anesthetic complications including reactions to general, spinal, or epidural anesthesia
25. Abnormal PAP smears
26. Uterine abnormalities or exposure to DES
27. Infertility
28. ART Assisted Reproductive Technology including In Vitro Fertilization
29. Family History of any of the above
30. Other problems not listed above
B. INFECTION HISTORY
1.
Tuberculosis exposure
2.
Genital Herpes exposure
3.
Rash or viral illness since Last Menstrual Period
4.
Hepatitis B or C illness or exposure
5.
STD, Gonorrhea, Chlamydia, HPV, HIV or Syphilitic illness or exposure
6.
Other infections or exposures to infectious diseases not listed above
C. GENETIC SCREENING: Includes Patient, Baby’s Father, or Anyone in Either Family
1.
Will you be age 36 years or older by the time of your Estimated Date of Delivery?
2.
Thallassemia anemia or Italian, Greek, Mediterranean or Asian background
3.
Neural tube defects including spina bifida, meningomyelocele or anencephaly
4.
Congenital Heart Defects
5.
Down’s syndrome, Mongolism or Mental Retardation
6.
Tay-Sachs disease, or Ashkenazi Jewish, Cajun, or French Canadian background
7.
Canavan disease, or Ashkenazi Jewish background
8.
Familial dysautonomia or Ashkenazi Jewish background
pre-natal questionnaire / revised june 18, 2011
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YES
N0
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TOMS RIVER OB-GYN ASSOCIATES
PRE NATAL QUESTIONNAIRE
Patient Name____________________________________________________Date_____/_____/_____
DO YOU HAVE A HISTORY OF ANY OF THE PROBLEMS OR DISORDERS LISTED
BELOW?
C. GENETIC SCREENING: Includes Patient, Baby’s Father, or Anyone in Either Family
9.
Sickle cell disease or trait, or African background
10. Hemophilia, tendency to bleed, or other blood disorders
11. Muscular Dystrophy
12. Cystic Fibrosis
13. Huntington’s Chorea
14. Mental Retardation or Autism
15. Other Inherited, Genetic, or Chromosomal Disorders
16. Maternal metabolic disorders such as Type 1 Diabetes or Phenylketonuria PKU
17. Do you or the baby’s father have a child with a birth defect? Cleft lip or palate?
18. Recurrent pregnancy losses or a Stillbirth
19. Medications including supplements, vitamins, herbs, OTC drugs taken since last period
20. Any other Genetic Disorders or Exposure to Agents not listed above
D. RISKS FACTORS
PATIENT PROFILE
1.
Are you younger than 20 or older than 35?
2.
Do you have less than an 8th grade education?
3.
Were you ever told that you have a small pelvis?
4.
Are you shorter than 5 feet (60 inches)?
ADDICTION
5.
Have you ever been addicted to Alcohol?
6.
Have you ever been addicted to Drugs?
7.
Have you ever been addicted to Smoking?
SOCIAL FACTORS
8.
Have you ever been in an abusive relationship?
9.
Do you have Cats in the house?
10. Is there no Family Support for this Pregnancy?
11. Do you have a poor living environment?
12. Do you have significant social problems?
GYNECOLOGICAL HISTORY
13. Have you had previous surgery on the cervix or damage or tears to the cervix?
14. Do you have a history of a weak or incompetent cervix?
15. Do you have a history of difficulty becoming pregnant or infertility?
16. Have you had any past surgery of the uterus such as removal of fibroid tumors?
17. Have you previously had any Abnormal PAP Smears?
18. Do you have abnormalities of the uterus such as a double uterus or double cervix?
OBSTETRICAL FACTORS/PARITY
19. Will this be the first time for you to give birth?
20. Have you given birth at least 5 (five) times?
PAST PREGNANCIES
21. Have you had 2 (two) or more abortions (either spontaneous or induced)?
22. Have you had 7 (seven) or more prior deliveries?
23. Have you ever had an abnormal labor? ABO incompatability?
24. Have you ever had difficulty with any type of Anesthesia
25. Have you ever had a weak or incompetent cervix or a need to put a stitch in the cervix?
26. Have you ever had an infection of the Womb, Chorioamnionitis, or Strep infection?
27. Have you ever given birth to a fetus or infant with Congenital abnormalities?
28. Have you ever had a previous Cesarean section?
pre-natal questionnaire / revised june 18, 2011
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YES
N0
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TOMS RIVER OB-GYN ASSOCIATES
PRE NATAL QUESTIONNAIRE
Patient Name______________________________________________________Date_____/_____/_____
DO YOU HAVE A HISTORY OF ANY OF THE PROBLEMS OR DISORDERS LISTED
BELOW?
D. RISKS FACTORS
PAST PREGNANCIES continued
29. Have you ever had a pregnancy resulting in a stillborn, or loss of an infant?
30. Have you ever had Diabetes in a previous pregnancy?
31. Have you ever hemorrhaged during a previous pregnancy?
32. Have you ever given birth to an infant weighing over 9 pounds (4000 grams) ?
33. Have you ever had a pregnancy with an infant that was small or failed to grow?
34. Have you ever had a pregnancy where you pre-natal care was late in the pregnancy?
35. Have you ever given birth to a Low Birth Weight Infant?
36. Have you ever delivered an infant that was Neurologically damaged?
37. Have you ever had a pregnancy where there was little or no fluid around the baby?
39. Have you ever had a pregnancy where there was too much fluid in the sac around the baby?
40. Have you ever had a pregnancy with toxemia or pre-eclampsia?
41. Have you ever had a pregnancy with High Blood Pressure?
42. Have you ever had a pregnancy with a Pre-Term Birth or Premature Baby?
43. Have you ever broken your water bag early during a pregnancy?
44. Have you ever been diagnosed with Rh Disease during or after a pregnancy?
45. Are you allergic to Latex?
46. Would you decline to have a Blood Transfusion in an emergency?
YES
N0
PLEASE GIVE EXPLANATIONS TO ALL OF THE YES ANSWERS EITHER BELOW OR ON THE BACK OF THE PAGE:
I CERTIFY that I have read all of the questions in this pre-natal questionnaire and have answered them to the best of my knowledge.
Furthermore, any questions that I did not understand were explained to me by my physician.
PRINTED NAME OF PATIENT________________________________________________________DOB_____/_____/_____
SIGNATURE OF PATIENT____________________________________________________________DATE_____/_____/_____
PHYSICIAN________________________________________________________________________WITNESS_____________
pre-natal questionnaire / revised june 18, 2011
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