Prenatal Visit Intake Form

Today's Date

Parent's Name

Age

Anticipated length of time off after infant birth

PREGNANCY HISTORY

What is your estimated due date?

Is this your first pregnancy?

Yes No

If no, any problems with your previous pregnancies?

Yes No

Any prior miscarriages or terminations?

Yes No

Was IVF used for conception?

Yes No

Was IVF used for conception?

Yes No

If yes, Please Explain

Did you have an ultrasound at/or around 20 weeks gestation?

Yes No

Were there any problems noted with this ultrasound?

Yes No Unsure

Do you know the sex of your baby?

Yes No Unsure

If you have a boy, do you want a circumcision?

Yes No Unsure

Where are you planning on delivering your baby?

Alta Bates UCSF CPMC Other

if Other, Specify

Who is your OBGYN or midwife?

POSTPARTUM

How do you plan to feed your newborn?

Breastfeed Formula Unsure

FAMILY SOCIAL HISTORY

Do you have other children?

Yes No

Do you have a pool or hot tub?

Yes No

Are there smokers in your household?

Yes No

Do you have guns in your home?

Yes No

Do you have pets in your home?

Dogs Cats Other

If other, Please specify

Is your home single or multiple stories?

Yes No

Is your home built before 1980?

Yes No

If yes, is there peeling paint or ongoing renovations?

Yes No

BIOLOGICAL MOTHER'S HEALTH

Any health problems?

Yes No

Any prior diagnosis or treatment for depression, anxiety or other mental health concerns?

Yes No

Any history of a positive PPD or history of tuberculosis?

Yes No

If yes, Please explain

BIOLOGICAL FATHER'S HEALTH

Any health problems?

Yes No

Any prior diagnosis or treatment for depression, anxiety or other mental health concerns?

Yes No

Any history of a positive PPD or history of tuberculosis?

Yes No

If yes, Please explain

Family Medical history (if yes, please indicate if maternal/ paternal and degree of family member):

Congenital heart condition

Yes No

Lungs problems

Yes No

Seizures

Yes No

Learning Disability

Yes No

Developmental Delay

Yes No

Congenital Hip Problems

Yes No

Jaundice

Yes No

Have you / your partners / household members had Tdap and flu vaccinations?

Yes No

Would you like to have a Tdap vaccine at today’s visit?

Yes No

Would you like to receive a Flu vaccine at today’s visit?

Yes No

Do you plan to vaccinate your child according to the recommended schedule?

Yes No

Do you plan to receive routine newborn hospital care (erythromycin eye ointment, Hep B vaccine, Vit K injection)

Yes No

Are there any other specific questions we can help address?

Yes No

If yes, Please explain below

How did you hear about our practice?

Website

Internet Search

Yelp

Magazine

Mail / Print

Friend / Family Referral

Physician Referral

Alta Bates Information Session

Other

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