• Sandpoint Women's Health

  • New OB Patient Health History Form

    Please don't leave any section blank.  If non or not applicable, write N/A.

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  • Father of the baby

  • Menstrual History

  • Reproductive History

  • List previous pregnancies in order. Please include abortions (TAB) and/or miscarriages (SAB)

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  • Past Medical History

    This is your history only. Answer yes if you ever have or have had these and the year diagnosed.
  • Past Surgical History

    List all surgeries and their year.
  • Medications/supplements

  • Family Medical History

  • Please list: (F)father, (M)mother, (PGF) paternal grandfather, (PGM) paternal grandmother, (MGF)maternal grandfather, (MGM)maternal grandmother, (S) sibling, (A) aunt, (U) uncle etc.

    Add age of diagnosis if known.

  • Social History

  • Genetic History

    Include patient, baby's father, or anyone in either family with:
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  • Should be Empty: