PRENATAL VISIT / FIRST TIME NEWBORN (UP TO 2 MONTHS OLD)

Baby’s name (if applicable):

Due / birth date:

Today's Date:

Referred by:

OB / Midwife:

Hospital of delivery:

What is the sex of the baby?

Boy Girl Unknown

Are you or do you plan to breastfeed?

Yes No Don't know

Have you had any breast surgeries?

Yes No Don't know

Did you or do you plan to circumcise?

Yes No Don't know

Mother’s name:

Occupation:

Age:

Father's name:

Occupation:

Age:

Sibling’s name:

Medical problems:

Age:

Add new row

Marital status:

Married Single Separated Divorced Other

If other, please specify:

Who does / will the child live with after the child is born?

Does anyone in the home smoke cigarettes, drink alcohol or use street drugs?

Yes No

Does your family observe any special diets?

Yes No

Religious / spiritual affiliations?

OBSTETRIC HISTORY:

Any previous pregnancies?

Yes No

Any miscarriages, abortions or stillbirths?

Yes No

Any complications or concerns during this pregnancy? (infections, diabetes, high blood pressure, other)

Did the babies have any complications at birth?(jaundice, feeding problems)

MOTHER’S MEDICAL HISTORY:

Allergies:

Medications (including vitamins and herbals):

Medical Problems/Issues:

FATHER’S MEDICAL HISTORY:

Allergies:

Medications (including vitamins and herbals):

Medical Problems/Issues:

FAMILY HISTORY:

Has anyone in the family ever had or been treated for the following? (Include the child’s siblings, mother, father, grandparents, aunts and uncles.)

Allergies

Yes No

If yes, with whom:

Anemia

Yes No

If yes, with whom:

Positive PPD/TB

Yes No

If yes, with whom:

High blood pressure

Yes No

If yes, with whom:

High Cholesterol

Yes No

If yes, with whom:

Bowel problems:

Yes No

If yes, with whom:

Thyroid problems

Yes No

If yes, with whom:

Depression / psychiatric

Yes No

If yes, with whom:

Stroke

Yes No

If yes, with whom:

Cancer

Yes No

If yes, with whom:

Food allergy/intolerance

Yes No

If yes, with whom:

Wheezing, asthma, bronchitis

Yes No

If yes, with whom:

Eczema or skin problems

Yes No

If yes, with whom:

Heart problems

Yes No

If yes, with whom:

Hepatitis or liver problems

Yes No

If yes, with whom:

Diabetes

Yes No

If yes, with whom:

Kidney problems

Yes No

If yes, with whom:

Drug or alcohol problems

Yes No

If yes, with whom:

Seizures

Yes No

If yes, with whom:

Other:

If the baby is already born, please fill out the following:

Hospital of delivery:

Please select:

Vaginal delivery C-section

Birth weight:

Gestational Age (number of weeks):

If male, was he circumcised?

Any complications? (jaundice, low glucose, antibiotics needed)

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