New OB History Form

New OB Patient Health History Form

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

Today's Date

Date

Patient Name

Date of Birth

Date

Age

Religious Preference

Occupation

MARITAL STATUS:

Single Married Divorced Partner

Jewish ancestry:

YES NO

Ethnicity:

Height:

Name

Age

Height

Weight

Occupation

Ethnicity

Jewish ancestry:

YES NO

First day of last menstrual period

If you are not sure, click "unknown" below

Unknown

Age at first period

Periods regular Irregular

Days between periods

How long do periods last

Periods

Are periods heavy Moderate Light

Spotting Since last period?

YES NO

When

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

Date - Pregnancy #1

Date

Place of Birth

Number of weeks Pregnant

Length of Labor

Type of Meds Used

Vaginal or C-section

Birth Weight

Sex of baby

Complications

Date - Pregnancy #2

Date

Place of Birth

Number of weeks Pregnant

Length of Labor

Type of Meds Used

Vaginal or C-section

Birth Weight

Sex of baby

Complications

Date - Pregnancy #3

Date

Place of Birth

Number of weeks Pregnant

Length of Labor

Type of Meds Used

Vaginal or C-section

Birth Weight

Sex of baby

Complications

Date - Pregnancy #4

Date

Place of Birth

Number of weeks Pregnant

Length of Labor

Type of Meds Used

Vaginal or C-section

Birth Weight

Sex of baby

Complications

Date - Pregnancy #5

Date

Place of Birth

Number of weeks Pregnant

Length of Labor

Type of Meds Used

Vaginal or C-section

Birth Weight

Sex of baby

Complications

Date of last Pap Smear

Date

Date of last Pap Smear

Never had one

Ever have an adnormal Pap.

YES NO

If yes to an abnormal Pap, were you treated:

Cryotherapy Laser Cone Biopsy LEEP

Have you been told you have a Uterine Anomaly (ie. tilted, retroverted, heart shape)

YES NO

Have you ever experienced Sexual Abuse or trauma?

Never Past Current

Have you ever been physically abused?

Never Past Current

Have you ever been mentally abused?

Never Past Current

Have you or the father of the baby EVER had a sexually transmitted disease. (Even treated)

Comments

DIABETES

DIABETES - YES DIABETES - NO

DIABETES YEAR

ANEMIA

YES NO

ANEMIA YEAR

HYPERTENSION

YES NO

HYPERTENSION YEAR

HEART DISEASE

YES NO

HEART DISEASE YEAR

AUTOIMMUNE DISORDER

YES NO

AUTOIMMUNE DISORDER YEAR

KIDNEY DISEASE/UTI'S

YES NO

KIDNEY DISEASE/UTI'S YEAR

NEUROLOGIC/EPILEPSY

YES NO

NEUROLOGIC/EPILEPSY YEAR

PSYCHIATRIC/MOOD DISORDER

YES NO

PSYCHIATRIC/MOOD DISORDER - YEAR

DEPRESSION

YES NO

DEPRESSION - YEAR

MIGRAINES

YES NO

MIGRAINES- YEAR

HEPATITIS / LIVER DISEASE

YES NO

HEPATITIS / LIVER DISEASE - YEAR

VARICOSE VEINS / PHLEBITIS

YES NO

VARICOSE VEINS / PHLEBITIS - YEAR

THYROID DYSFUNCTION

YES NO

THYROID DYSFUNCTION - YEAR

TRAUMA / MOTOR VEHICLE ACCIDENT

YES NO

TRAUMA / MOTOR VEHICLE ACCIDENT - YEAR

HISTORY BLOOD TRANSFUSION

YES NO

HISTORY BLOOD TRANSFUSION - YEAR

RHOGAM FOR NEGATIVE BLOOD

YES NO

RHOGAM FOR NEGATIVE BLOOD - YEAR

PULMONARY (TB, ASTHMA)

YES NO

PULMONARY (TB, ASTHMA) - YEAR

CHICKEN POX

YES NO

CHICKEN POX - YEAR

EATING DISORDER

YES NO

EATING DISORDER - YEAR

OTHER

YES NO

OTHER - YEAR

Past Surgical History

NONE

Surgery #1

Surgery #1 YEAR

Surgery #2

Surgery #2 YEAR

Surgery #3

Surgery #3 YEAR

Surgery #4

Surgery #4 YEAR

Name #1

Dose

# times a day

Name #2

Dose

# times a day

Name #3

Dose

# times a day

Name #4

Dose

# times a day

Medical allergies:

Latex

YES NO

Eggs

YES NO

Medical Allergies

None

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.

Diabetes

Ovarian Cancer

Heart Disease

Endometrial Cancer.

High Blood Pressure.

Colon Cancer

Lung Disease.

Thyroid Disease

Breast Cancer

Other family medical history

Are you a smoker

Yes No Never

How much before Pregnancy?

How much Now?

Alcohol

Yes No Never

How much before Pregnancy?

How much Now?

Street Drugs (including marijuana)

Yes No Never

Type

PATIENT'S AGE IS 35 YEARS OR OLDER

YES NO

THALASSEINIA (ITALIAN, GREEK, MED, ASIAN)

YES NO

NEURAL TUBE DEFECT

YES NO

CONGENITAL HEART DEFECT

YES NO

DOWNS SYNDROME

YES NO

TAY-SACHS

YES NO

SICKLE CELL DISEASE

YES NO

HEMOPHILIA

YES NO

MUSCULAR DYSTROPHY

YES NO

CYSTIC FIBROSIS

YES NO

HUNTINGTON CHOREA

YES NO

MENTAL RETARDATION / AUTISM

YES NO

INHERITED GENETIC OR CHROMOSOMAL DISORDER

YES NO

MATERNAL METABOLIC DISORDER

YES NO

PATIENT OR BABY'S FATHER HAD CHILD WITH BIRTH DEFECT NOT LISTED

YES NO

RECURRENT MISCARRIAGE OR STILLBIRTHS

YES NO

MEDICATIONS/STREET DRUGS/ALCOHOL SINCE LAST PERIOD

YES NO

IF YES, WHAT?

OTHER:

List any symptoms you have been having with this pregnancy:

ARE THERE CATS IN THE HOME?

YES NO

If Yes, who changes the cat box?

Are you around children on a regular basis?

YES NO

What do you do for exercise?

Please list any questions you may have regarding pregnancy:

Sandpoint Women's Health

Father of the baby

Menstrual History

Reproductive History

Past Medical History

Past Surgical History

Medications/supplements

Family Medical History

Social History

Genetic History