OBGYN/Labor & Delivery Intake Form
Connecting You with RRH Women's Health - Labor & Delivery Services
Personal Information
Name*
First Name
Last Name
Date of Birth*
-
Month
-
Day
Year
Date
Phone Number*
Primary contact number where we can reach you.
Email
example@example.com
Zip Code*
Best Time to Call*
Please Select
Morning - (8AM - 10AM PST)
Noon - (10AM - 12PM PST)
Afternoon - (12PM - 5PM PST)
Any Time
Let us know when it is most convenient to reach you.
Are You a Current RRH Patient?*
Yes
No
Current Provider:
Are You Currently Receiving Prenatal Care Elsewhere?*
Yes
No
Other Prenatal Care Hospital/Doctor:
Reason for Appointment*
Back
Next
Pregnancy Information
Please answer the following questions to the best of your ability. If you're unsure, provide your best estimate.
Estimated Due Date*
-
Month
-
Day
Year
Date
Current Weeks of Pregnancy*
Enter the number of weeks you have been pregnant.
How many total pregnancies have you had, including any miscarriages, stillbirths, or this current pregnancy?*
When was the first day of your last period?*
-
Month
-
Day
Year
Please provide the first day of your most recent menstrual period.
Are you a Surrogate?*
Yes
No
Does this current pregnancy involve In Vitro Fertilization (IVF)?*
Yes
No
Fertility Clinic Name*
Enter the name of the fertility clinic associated with this pregnancy.
Agency*
Enter the name of the agency managing this surrogacy, if applicable.
Fertility Clinic Phone*
Please provide the contact number for the fertility clinic.
Number of Living Children*
Have You Had Any Abortions?*
Yes
No
Have You Had Any Miscarriages?*
Yes
No
Number of Abortions*
Number of Miscarriages*
Have you had any C-Sections/VBAC?*
Yes
No
Number of C-Sections/VBAC*
Ectopic Pregnancy?*
Yes
No
Number of Ectopic Pregnancies*
Who was your provider for your last pregnancy?*
Was your last provider monitoring you during your last pregnancy for any reasons such as high blood pressure, diabetes, or any conditions such as high blood pressure, diabetes, or any other conditions?*
Yes
No
If Yes, describe in detail:*
Describe the conditions your provider monitored, if known.
Any family history that would be important to the doctor, such as heart conditions, seizures, high blood pressure, or diabetes?*
Yes
No
If Yes, describe in detail:*
List any family medical conditions that may impact your care, such as high blood pressure or seizures.
Do you currently take any medications or have any conditions?*
Yes
No
If Yes, describe in detail:*
List your medications and/or conditions, if known.
Are you okay with getting a blood transfusion if you should need one during delivery?*
Yes
No
Insurance Provider*
Please enter the name of your health insurance provider.
Submit
Should be Empty: