Patient Information & Pregnancy Questionnaire

Please correct the errors described below.

Last Name

First Name

Middle Initial

Date of Birth

Address

City

State

Zip

County

Occupation

Phone Number

SIGNIFICANT OTHER INFORMATION

Last Name

First Name

Middle Initial

Date of Birth

Occupation

PATIENT CONTACT INFORMATION

Cell

Home

Work

May we leave detailed voice messages that may include confidential medical information and test results?

No Yes

If yes, please provide a confidential phone number

Can we leave test results with anyone else?

No Yes

If yes, please provide information below

Name

Confidential #

REFERRING DOCTOR OR CLINIC INFORMATION

Name

Phone

Address

City

PREGNANCY AND EXPOSURE INFORMATION

Are you currently pregnant?

No Yes

Due Date

Have you taken any medications during this pregnancy (besides prenatal vitamins or Tylenol)?

No Yes

If yes, please list medications below:

Since becoming pregnant, have you had any (Or if not pregnant please check current exposures)

Recreational Drugs

No Yes

Describe (if needed)

Cigarettes

No Yes

Describe (if needed)

Alcohol

No Yes

Describe (if needed)

Do you have any of the following conditions?

Diabetes?

No Yes

Describe (if needed)

A seizure disorder?

No Yes

Describe (if needed)

Lupus?

No Yes

Describe (if needed)

Fevers (greater than 101* F)

No Yes

Describe (if needed)

X -rays (other than dental)

No Yes

Describe (if needed)

ALL OF THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

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