OB Patient History

(DO NOT LEAVE ANYTHING BLANK)

Patient:

Partner:

Date of Last Period:

Date of Home Pregnancy Test:

Age of First Period:

Period Cycle:

Regular Irregular

#Days Between Cycles:

28 30 Other

If other, specify days between cycle:

# Days of Bleeding:

Past Pregnancy History

Date:

Time Delivered am/pm:

GA (Number of weeks pregnant at the time of delivery):

Length of Labor:

Birth Weight:

Sex:

Vaginal or C-Section:

Epidural:

Hospital or City of Delivery:

Complication:

Add new row for another past pregnancy

Personal and Family Medical History

Allergic Rhinitis:

Yes No

Who?

Hypertension:

Yes No

Who?

Anemia/Hematologic:

Yes No

Who?

Infertility:

Yes No

Who?

Asthma/Pulmonary:

Yes No

Who?

Liver Disease:

Yes No

Who?

Abnormal Pap Smear:

Yes No

Who?

Neurologic Disorder:

Yes No

Who?

Autoimmune Disorder:

Yes No

Who?

Renal Disease:

Yes No

Who?

Blood Transfusion:

Yes No

Who?

(Rh) Sensitized:

Yes No

Who?

Breast Disorder:

Yes No

Who?

Thyroid Disorder:

Yes No

Who?

Depression:

Yes No

Who?

Trauma History:

Yes No

Who?

Psychiatric Disorder:

Yes No

Who?

Uterine Abnormalities:

Yes No

Who?

Diabetes:

Yes No

Who?

Varicosities or DVT:

Yes No

Who?

Heart Disease:

Yes No

Who?

Anesthetic Complications:

Yes No

Who?

Other Family History:

Yes No

Who?

If other family history, specify:

Substance Abuse

Tobacco:

Yes No

Amt/Day PrePregnant:

Amt/Day Pregnant:

# Years Use:

Alcohol:

Yes No

Amt/Day PrePregnant:

Amt/Day Pregnant:

# Years Use:

Illicit Drugs:

Yes No

Amt/Day PrePregnant:

Amt/Day Pregnant:

# Years Use:

Surgical History

Type of Procedure:

Year:

Comment:

Add new row for another procedure

Genetic Screening

Patient Age Over 35:

Yes No

What Relative?

Neural Tube Defect (Spina Bifida, Anenceohaly):

Yes No

What Relative?

Trisomy 21 (Down Syndrome):

Yes No

What Relative?

Congenital Heart Defect:

Yes No

What Relative?

Cystic Fibrosis:

Yes No

What Relative?

Tay-Sachs:

Yes No

What Relative?

Thalassemia:

Yes No

What Relative?

Canavan Syndrome:

Yes No

What Relative?

Hemophilia:

Yes No

What Relative?

Huntington's Chorea:

Yes No

What Relative?

Autism:

Yes No

What Relative?

If yes: Was person tested for Fragile X?

Yes No

What Relative?

Mental Retardation:

Yes No

What Relative?

If yes: Was person tested for Fragile X?

Yes No

What Relative?

Muscular Dystrophy:

Yes No

What Relative?

Sickle Cell Disease or Trait:

Yes No

What Relative?

Other Inherited Genetic Disorder:

Yes No

What Relative?

Maternal Metabolic Syndrome:

Yes No

What Relative?

Recurrent Pregnancy Loss:

Yes No

What Relative?

Other Birth Defects:

Yes No

What Relative?

Other Genetic Screening:

Yes No

What Relative?

Exposure/Infection History

Patient/Partner has History of HIV:

Yes No

Comment:

Patient/Partner has History of Genital Herpes:

Yes No

Comment:

Exposure to TB:

Yes No

Comment:

Had Varicella (Chicken Pox) as a child or adult:

Yes No

Comment:

Rash or Viral Illness since last menstrual period:

Yes No

Comment:

Sexually Transmitted Disease:

Yes No

Comment:

Other Exposure or Infection:

Yes No

Comment:

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