• OBSTETRIC MEDICAL HISTORY

    OBSTETRIC MEDICAL HISTORY

  • Birth Date
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  • Date Form Completed
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  • Format: (000) 000-0000.

  • Pregnancy History

  • There are several options in pregnancy. Are you considering:
  • If you could change the timing of this pregnancy, would you want it

  • 1. Have you ever had an allergic reaction to:

  • Penicillin?
  • A medication or vaccine?
  • Shellfish?
  • Latex?
  • 2. Please mark any condition that you have or have had in the past
  • 5. Do you or any family member have a history of problems with anesthesia?
  • 6. Do you have any objections to any form of medical treatment (eg, blood transfusion)

  • Exposures Affecting Health

  • 1. Do you currently or have you in the past year smoked, chewed, used any type of nicotine delivery system (ENDS), or vaped?
  • Do you currently or have you in the past year smoked, vaped, dabbed, or eaten marijuana?
  • 2. Do you drink alcoholic beverages now or did you before you became pregnant?
  • 4. Have you used any non-prescription or recreational drugs since your last menstrual period (eg cocaine, opiates)
  • 5. Do you have any reason to believe you or your sexual partner(s) may have been exposed to HIV/AIDS? This may include a history of blood transfusion, IV drug use, sex with men who have sex with other men or bisexual men, or sex with someone who has used IV drugs?
  • 6. Have you been exposed to chemicals (eg, pesticides, lead, hazardous material/agents) or radiation (eg X-rays) since you became pregnant?
  • 7. Do you have any dietary restrictions?
  • 8. Have you or your partner(s) recently traveled (eg, in the past 3 months) outside of the United States?

  • Gynecologic Health History

  • Have you ever had an abnormal Pap or other cervical cancer test?
  • Did you have any procedures on your cervix for treatment (eg, LEEP [loop electrosurgical excision procedure] or cold knife or laser conization)?
  • Have you ever had HPV?
  • Have you received your complete series of the HPV vaccine?
  • 2. Have you ever had one or more of the following?
  • 3. Have you ever had herpes?
  • Have you ever had syphilis?
  • 4. Were you using an intrauterine device (IUD) for contraception when you became pregnant?
  • 5. Have you been treated for infertility?
  • 6. Do you have any other concerns related to your past health history?

  • Family History and Genetic Screening

  • The following questions pertain to the genetic makeup of (or "genetics") of the current pregnancy. Please answer "yes" if the following applies to any person who is genetically related to the baby.

  • Please check if the baby has one of the following genetic backgrounds:

  • Ashkenazi
  • Black/African American
  • Mediterranean or South Asian Ancestry
  • French Canadian or Cajun Ancestry
  • Rows

  • If Genetic Carrier Screening was performed, when was it performed and what was the result?

  • 2. Does the baby have any genetic relatives born with a birth defect?
  • 4. Is there a history of pregnancy loss (miscarriages or stillbirths)?
  • If yes, has there been genetic counseling?
  • If yes, has there been genetic testing related to the history of pregnancy loss?
  • 5. Do you have a family history of fragile X syndrome, intellectual disabilities/cognitive delays, autism, or premature ovarian failure?

  • If yes, what were the results and when and where were this testing performed?

  • 7. Do you want screening test(s) to look for genetic or chromosomal problems like Down syndrome during your pregnancy?

  • Psychosocial Screening

  • 1. Do you have any problems (eg, job, transportation) that prevent you from keeping your health care appointments?
  • 2. In the last 12 months, have you ever had to go without health care because you did not have a way to get to your appointments?
  • 3. Are you afraid you might be hurt in your apartment building, home, or neighborhood?
  • 4. In the past year, have you been threatened, hit, slapped, or kicked by anyone you know?
  • 5. Has anyone forced you to perform any sexual act that you did not want to do?
  • 6. In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?
  • 7. In the last 12 months, has your utility company shut off your service for not paying your bills?
  • 8. Are you worried that, in the next 2 months, you may not have stable housing?
  • 9. Do problems getting childcare make it difficult for you to work, study, or get to health care appointments?
  • 10. In the last 12 months, have you needed to see a doctor but could not because of cost?
  • 11. Do you ever need help reading materials you get from your doctor, clinic, or the hospital?
  • 12. Are you scared of getting in trouble because of your legal status?
  • 13. Have you ever been incarcerated?
  • 14. Are you exposed to second-hand smoke?
  • 15. Have you had a past experience in the health care system with any racism/bias/discrimination?
  • 16. On a 1-5 scale how do you rate your current stress level (1=low stress, 5=high stress)
  • Next steps: If you answered yes to any of these questions, would you like to receive assistance with any of those needs?
  • DATE
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  • Version 9 | Copyright 2022 | The American College of Obstetricians and Gynecologists | www.acog.org | (AA402_9)

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