Download New OB Patient History - Vanderbilt University Medical Center

New OB Patient History
The Basics:
Current Medications: _____________________
Name: ________________________________
_______________________________________
Home phone #:__________________________
_______________________________________
Cell phone #: ___________________________
_______________________________________
Father of the Baby:
Education:
_______________________________________
□ Husband
□ Domestic Partner
Last Grade Level Completed:
□ High School
□ College
Years married / together? _________
□ Post Grad
Emergency Contact Person:
Did you have any special education needs in
_______________________________________
school?
Relationship to you:
How do you learn best?
yes
_______________________________________
□ Listening / watching
Emergency Contact Phone #:
□ Demonstration
_______________________________________
□ Reading
no
Background Information:
Are you enrolled in any of the following?
Your occupation:
WIC
yes
no
_______________________________________
Food Stamps
yes
no
Your Job Title:
Families First AFDC
yes
no
_______________________________________
Social Security
yes
no
Father of the Baby’s occupation:
How many meals do you eat in a day?
_______________________________________
Father of the Baby’s Job Title:
___________________
Do you have an advanced directive?
_______________________________________
yes
no
Your Race:
Do you want information about an advanced
_______________________________________
directive [living will]?
Your Country of birth:
yes
no
_______________________________________
Do you have any spiritual or cultural needs that
Your primary language spoken:
would effect how we care for you?
_______________________________________
Your Religion:
yes
no
Explain:________________________________
_______________________________________
_______________________________________
Drug Allergies?
_______________________________________
yes
no
Explain_________________________________
Do you have any objections to receiving blood
Are you allergic to latex?
yes
no
products?
Food allergies?
yes
no
Pre-pregnancy weight: ____________________
yes
no
Do you live in a:
Do you have a birth plan?
yes
no
□ House
GYN History
□ Apartment
Do you have your menstrual cycle every 28 – 30
□ Other___________________
days?
Where you live do you have the following?
yes
If not, how often?
no
___________________
Electricity
yes
no
What was the first day of your last menstrual
Water
yes
no
period? ________________________________
Well water
yes
no
How was your pregnancy confirmed?
Cooking facilities / kitchen
Stairs
□ Home pregnancy test
yes
no
yes
no
What is your current form of transportation?
□ Personal vehicle
□ Doctor’s office/clinic test
Medical History & Health Maintenance
Do you exercise regularly?
yes
no
Are your immunizations up to date?
□ Family and friends
yes
□ Public transportation
no
Do you drink alcoholic beverages?
□ TennCare transportation
yes
no
Planning for your baby?
Do you use street drugs?
yes
no
Do you have an infant car seat?
Do you smoke?
yes
no
yes
no
How do you want to feed your baby?
Past Pregnancies (please use another sheet of
paper if you need more room)
□ Breast and Bottle
Pregnancy #
□ Breast only
Month/Year of
□ Bottle only
Birth
□ Not sure
Male / Female
Birth weight
If your baby is a boy, do you want him
circumcised?
yes
no
Vaginal birth,
When you deliver your baby, what type of pain
c-section,
medication do you want?
miscarriage,
or abortion
□ Epidural
Pain
□ IV Medicine
Management
□ None
What type of birth control do you want to use
after your baby is born?
Feeding
Breast or
Bottle
□ Pills
Childs Name
□ Depo Provera Injections
Weeks at time
□ IUD
of delivery
□ Permanent Sterilization
Hours in labor
□ Unsure
Problems?
Will your baby be placed for adoption?
yes
no
1
2
3
4
Medical History and Health Maintenance
Patient
Family
Unsure
Multiple Births [i.e. twins]
Yes
No
Yes
No
Malignancies [i.e. cancer]
Yes
No
Yes
No
Hypertension [i.e. high blood pressure]
Yes
No
Yes
No
Heart Disease
Yes
No
Yes
No
Pulmonary Disease [i.e. asthma]
Yes
No
Yes
No
GI Problems [i.e. crohn’s disease]
Yes
No
Yes
No
Breast Disease
Yes
No
Yes
No
Urinary tract problems [including UTI’s &
Yes
No
Yes
No
Endocrine/Metabolic [i.e. diabeties/thyroid]
Yes
No
Yes
No
GYN problems
Yes
No
Yes
No
Abnormal pap smears
Yes
No
Yes
No
Fibroids
Yes
No
Yes
No
Abnormal uterine bleeding
Yes
No
Yes
No
Incompetent cervix
Yes
No
Yes
No
Other: ____________
Yes
No
Yes
No
Infertility/recurrent miscarriage
Yes
No
Yes
No
STD’s, HPV, Group B Strep, Herpes
Yes
No
Yes
No
Phlebitis/varicosities
Yes
No
Yes
No
Neurological [i.e. seizures]
Yes
No
Yes
No
Psychiatric [i.e. depression]
Yes
No
Yes
No
Immunologic/infectious disease
Yes
No
Yes
No
Operations/ accidents
Yes
No
Yes
No
Hematologic [i.e. Anemia]
Yes
No
Yes
No
Other hospitalizations:
Yes
No
Yes
No
Yes
No
Yes
No
Pyelo]
[i.e. varicose veins, blood clots]
[i.e. Lupus or HIV]
_______________________
History of sexual or physical abuse /
trauma
Genetics: Mother & Father
and Your Families History
Patient
Family
Unsure
Patient age >34 at delivery
Yes
No
---
---
Thalessemia; MCV < 80
Yes
No
Yes
No
Neural Tube Defect
Yes
No
Yes
No
Congenital Heart Defect
Yes
No
Yes
No
Down Syndrome
Yes
No
Yes
No
Jewish, Cajun, French Canadian [tay
Yes
No
Yes
No
Jewish: Canavan Disease, Gauchers
Yes
No
Yes
No
Sickle Cell Disease [African American or
Yes
No
Yes
No
Hemophilia or other blood disorders
Yes
No
Yes
No
Muscular Dystrophy
Yes
No
Yes
No
Cystic Fibrosis
Yes
No
Yes
No
Huntington’s Chorea
Yes
No
Yes
No
Mental Retardation / Autism [if yes was it
Yes
No
Yes
No
Other inherited or chromosomal disorder
Yes
No
Yes
No
Other structural birth defect
Yes
No
Yes
No
Maternal metabol/endocrine disorders
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Tobacco, Alcohol, Drugs
Yes
No
Yes
No
Any other:
Yes
No
Yes
No
sachs]
Caribbean]
fragile x? _______]
[diabetes, PKU]
Patient or baby’s father had a birth defect
not listed above:
________________________
Recurrent pregnancy loss [>2] and/or
stillbirth
________________________
Vanderbilt Center for Women’s Health – phone 615-343-5700 / fax 615-343-6724
One Hundred Oaks – 719 Thompson Lane, Suite 27100, Nashville TN 37204
Cool Springs – 2009 Mallory Lane, Suite 230, Franklin TN 37067
Clarksville – 647 Dunlop Lane, Suite 206, Clarksville, TN 37040