Please complete and bring this questionnaire before your first prenatal visit and bring it with you. We will review it with you.

GENERAL INFORMATION (Please Print)

MEDICAL ALLERGIES:

Which drugs or medicines are you allergic or sensitive to?

Patient information

Name:_______________________________________________________________________________________

Address:______________________________________________________________________________________

Phone: Day (___) ____- ______ Even. (___) ____- ______ Cell (___) ____- ______

Emergency (___) _____- _______

Age: ____ Date of Birth: ______ Marital Status: Married Single Widowed

Divorced Separated

Ethnic Group/Race: ________ ___Religion: ______________Occupation: ______________

Yrs of Educ.: ____yrs

Who to contact in an emergency: ________________Relationship: _____________

Phone: (___) ____- _______

Spouse/Significant Other Information

Name of Spouse/Significant Other: __________________

Is this the father of your baby? Yes No Age: _____

Phone numbers:Day (___) ____- ______ Even.: (___) ____- _______

Cell (___) ____- ______ Emergency (___) ____- ______

Ethnic Group/Race: _______________Religion: ___________Occupation: ______________

Yrs of Educ.: ____yrs

MENSTRUAL HISTORY/DATING INFORMATION

1  Date of the first day of your last period: ____________

Definite Approximate Unknown

2. Was your period normal in number of days of flow? yes, normal No, abnormal

3. Normal cycle length: _______days 4. Date of conception, if known: ____________

5. Where you on birth control pills/Depo shots when your last period started? Yes No

If so When did you last take them/it: _____

7. Were you breastfeeding when your last period started? YES No Date stopped:

________

8. Have your had a pos. pregnancy test? YES NO Date: ______

If yes, was it at home clinic

PREVIOUS PREGNANCIES (List all previous pregnancies, include miscarriages or abortions)

Any gestational diabetes during your pregnancies? YES NO

If yes, explain: _________________________

Any problems during any of your prior pregnancies? YES NO

If yes, explain: ________________________

PAST MEDICAL/SURGICAL HISTORY

Have you ever had (If yes, please explain and note date):

YES NO

1. Diabetes (high blood sugar)?

____________________________________________________________

2. Hypertension (High Blood Pressure) ?

_____________________________________________________

3. Heart disease/congenital heart disease/defects, mitral valve prolapse

or rheumatic fever?__________

4. Autoimmune disease such a s lupus or rheumatoid arthritis?

___________________________________

5. Kidney disease, kidney infection, urinary tract or many bladder infections?

_______________________

6. Migraine headaches, Strokes or seizures?

__________________________________________________

7. Any other neurological problems?

_________________________________________________________

8. Have you ever required psychiatric care?

__________________________________________________

9. Have you ever had hepatitis, liver disease or jaundice?

_______________________________________

10. Have you ever had varicose veins or hemorrhoids?

__________________________________________

11. Have you ever been treated for blood clots in your veins, deep venous thrombosis,

inflammation in the veins, thrombosis, phlebitis or pulmonary embolism?

If so, please state which and when: ___________________

12. Have you had excessive bleeding after surgery or dental work?

_________________________________

13. Do you bleed more than other women do after a cut or a scratch?

_______________________________

14. Do you have a history of anemia?

__________________________________________________________

15. Have you ever had a thyroid problems or taken thyroid medications?

_____________________________

16. In the last year, has anyone forced you to have sex when you did

not want to? If so, who? _____________________

17. In the last year, has anyone hit, slapped, kicked or otherwise hurt you?

If YES, who? _____________________________________

18. Have you ever been in a major accident or suffered serious injuries

or broken bones? ________________________________________________

19. Have your ever received a blood transfusion?

_________________________________________________

20. Do you have a religious or other reason you would

refuse a “life-saving” blood transfusion?___________

ALCOHOL/TOBACCO/DRUGS

Have you ever used any of the following:

Tobacco/Cigarettes? YES NO If YES, how much and when:

________________________________________

Alcohol, beer, wine? YES NO If YES, how much and when:

________________________________________

Street drugs? YES NO If YES, which ones, how much and when:

___________________________________

Does anyone in your household smoke? YES NO

Does your partner abuse alcohol or drugs? YES NO

YES NO

21. Is your blood type Rh negative? YES NO Not sure

22. Have you ever developed abnormal antibodies in your blood?

IF YES, has this caused a problem with a previous pregnancy? YES NO

If YES, please explain: ____________________________________________

23. Have you ever had asthma or tuberculosis ?

YES NO If YES, please explain: _________________

PAST MEDICAL/SURGICAL HISTORY

YES NO

24. Have you ever had any breast problems?

__________________________________________________

25. Have our ever had any problems with breastfeeding?

________________________________________

26. Have you ever had any gynecological surgical procedure such as:

Cervical Conization If yes, when and where:

____________________________________________________

Leep Procedure If yes, when and where:

_______________________________________________________

Laser treatment If yes, when and where:

______________________________________________________

Cryosurgery of the cervix If yes, when and where:

______________________________________________

Dilation and curettage (D & C) If yes, when and where:

__________________________________________

27. Have you ever had any other surgical procedures?

___________________________________________

___________________________________________________

28. Have you ever been hospitalized for a non-surgical reason other

than a normal delivery? ___________________________________________

29. have you ever had any complications or problems from anesthesia?

If YES, please explain when and where:

___________________________________________________________________

30. Have you ever had an abnormal PAP smear?

_______________________________________________

31. Do you or anyone in your family have a history of an abnormal uterus?

_________________________

32. Did your mother take DES or any other hormones

when she was pregnant with you to prevent miscarriage?

__________________________________________________________

33. Did it take more than one year to become pregnant?

_________________________________________

34. Have you ever been evaluated or treated for infertility?

_______________________________________

35. Is there a history of medical problems in you family that you feel might adversely

affect you health or this pregnancy? _______________________________________________

36. Do you have any other problem we have not asked about which

you feel might be of importance to this pregnancy? If YES, what?

____________________________________________________________

37. Have you had any symptoms or problems since your last menstrual period?

____________________________________________________________________________

GENETIC HISTORY

YES NO

1. Will you be age 35 or older at delivery?

____________________________________________________

2. Are you or the baby's father of Mediterranean ancestry?

Has either of you been screened for Thalassemia?

If YES, please indicate who was screened and the result: ______________________________

Have you, the baby's father or anyone in either family had one of the following:

YES NO

3. Brain, spinal cord or neural tube defects, meningomyelocel (open spine),

spina bifida or anencephaly?

________________________________________________________________

4. congenital hear disease/defect?

____________________________________________________________

5. Down Syndrome?

________________________________________________________________________

6. Are you or the father of the baby of Jewish, Cajun

or French Canadian descent? Has either of you been

screened for Tay-Sachs and/or Canavan's disease?

If so, indicate who was screened and the results.

_______________________________________________________________________

7. you of the father of the baby of African American ancestry?

Has either of you been screened for sickle cell disease or trait?

___________________________________________________________

If so, indicate who was screened and the results:

___________________________________________________

8. Hemophilia (blood that does not clot well)

or any other inherited blood clotting disease? ______________

9. Muscular Dystrophy, Huntington's Chorea, or Cystic Fibrosis:

____________________________________

10. mental retardation or autism?

If YES, was the person tested for fragile X? ________________________

11. Other inherited genetic or chromosomal disorders?

IF YES, please identify: ______________________

Do you or the baby's father have:

12. Insulin dependent diabetes, phenylketonuria or any other metabolic disorder?

____________________

13. A prior child with a birth defect not listed above?

___________________________________________

14. three or more miscarriages or a prior stillbirth?

_______________________________________________

15. Used any medications, alcohol or drugs since your pregnancy?

________________________________

_________________________________

16. Is there anything else you think we should be aware of?

_____________________________________

_____________________________________

INFECTION HISTORY

YES NO

1. have your ever received BCG (BCG, a shot to prevent TB,

is not given routinely in the US) ___________

2. have you ever had a positive skin test for Tuberculosis (TB)?

___________________________________

3. Do you live with someone who has had Tuberculosis

or have you been exposed to Tuberculosis? __________

4. Do you have genital herpes?

_____________________________________________________________

5. Does your partner have genital herpes?

_____________________________________________________

6. Have you had a rash or a viral illness since your last period?

____________________________________

7. have you ever had gonorrhea, Chlamydia, Syphilis,

Trichomoniasis,or any other STD's? ______________

8. If known, are you a Group B Streptococcus carrier? unknown

__________________________________

9. Have you ever had chickenpox/varicella?

____________________________________________________

10. Have you ever been vaccinated against chickenpox?

_________________________________________

11. have you ever had any other infectious diseases that could affect this pregnancy?

__________________

12. Do you have any cats at home?

____________________________________________________________