First Prenatal Visit Questionnaire

Name

Date of Birth

CareCard PHN

Address

Email address

Phone Number

Alternate Phone Number

Do you consent to receiving electronic communication from The Surrey Prenatal Clinic?

Yes No

Family Doctor

Are you a Canadian citizen or Permanent Resident?

Yes

No

Please enter the expiry date of your BC Care Card

Are you being seen by any other maternity provider? (e.g midwife or obstetrician)

Yes No

Are you planning to deliver your baby at the Surrey Memorial Hospital?

Yes No

Would you like to switch healthcare providers and be followed only by SPNC physicians?

Yes No

How did you hear about our clinic?

Current height

Weight

Pre pregnancy weight

How many weeks pregnant are you?

What type of work do you do?

How many hours per week?

Do you do shift work?

Yes No

Can you communicate in English?

Yes No

Can you bring someone to translate to English at your appointment?

Yes No

What language do you speak at home?

What type of reaction occurs during your allergies? (rash, throat swelling, shortness of breath)

Married/Partnered?

Yes No

Is your partner the biological father (or donor) for this pregnancy?

Yes No

Partner’s Occupation

Partner’s Name

Partner’s Age

What is the age of the biological father (or donor)

Add new row

Are you taking Folic Acid?

Yes No

When did you start taking it?

Do you have any allergies?

Yes No

If so, to what?

1) Obstetrical History, Including Abortions

Have you had any previous pregnancies before (include all miscarriages and abortions?

Yes No

If so, please list –miscarriages or abortions

What year(s) did it occur?

How many weeks were you at the time?

Did you need a D&C or any operations performed?

2) Birth Summary and Record (One row per child)

Add new row

Did you have any unusual circumstances that happened during your pregnancies that we need to know about? (fast delivery, heavy bleeding, retained placenta, shoulder dystocia, breech)

When was the first day of your last menstrual period?

Is your cycle

Regular Irregular

If regular, does it come every 28 days?

Yes No

If not, how many days does it come?

Have you had any ultrasounds yet?

Yes No

What was the name and location of the imaging centre?

Add new row

3) Present Pregnancy

Was it conceived through IVF?

Yes No

Any spotting or bleeding?

Yes No

If yes, at how many weeks?

Any nausea?

Yes No

If yes, is it mild, moderate or severe?

Is it getting better, worse, or the same?

Have you travelled outside North America during this pregnancy?

Yes No

Where did you go?

Any infections or fevers

Yes No

If so, what type of infection?

Depression?

Yes No

If yes, have you discussed this with anyone?

Were you ever on antidepressants before?

Yes No

If yes, for how long?

4) Family History

Heart Disease (heart attacks, bypass surgery, strokes, heart failure)

Yes No

Which relatives?

High Blood pressure

Yes No

Which relatives?

Diabetes

Yes No

Which relatives?

Problems with anesthesia?

Yes No

Which relatives?

Depression or Psychiatric Problems

Yes No

Which relatives?

Alcohol Abuse

Yes No

Which relatives?

Drug Abuse

Yes No

Which relatives?

Blood clots in the legs or lungs Or clotting disorders

Yes No

Which relatives?

Bleeding Disorders

Yes No

Which relatives?

Birth Defects

Yes No

If yes, what kind of defect?

Did you go see a genetic counsellor?

Yes No

Congenital Hip Dysplasia (ie. Family member that needed double diapering or early hip replacement)

Yes No

Inherited Conditions? (i.e Tach-Sachs, Sickle Cell Anemia, Thalassemia, Congenital Heart Defect, Cystic Fibrosis"

Yes No

Provide Details

5) Personal Medical History

Please answer Yes or No to the questions below and provide additional details as needed.

When was your last PAP test?

Are you vaccinated for Covid-19?

Yes No

When was your last Covid-19 vaccination?

Have you had the influenza vaccine (flu shot?)

Yes No

When was your last flu shot?

Do you use contraception / birth control?

Yes No

If yes, what kind?

Surgery (include therapeutic abortions, breast augments, plastic surgery, wisdom teeth)

Yes No

When were the surgeries and reason?

Anesthetics

Yes No

Provide details:

Uterine or cervical procedures? (cone biopsy, laser surgery for abnormal paps)

Yes No

Provide details:

Heart or lung problems

Yes No

Provide details:

Asthma

Yes No

Are you on any puffers?

Soft tissue injuries or back/spine problems

Yes No

Provide details:

Serious infections or sexually transmitted diseases. ( i.e genital herpes, gonorrhoea, chlamydia)

Yes No

When and What type?

Prior chicken pox

Yes No

Blood clots in the legs or lungs

Yes No

Provide details:

High blood pressure

Yes No

If so, name of medications

Stomach problems (irritable bowel syndrome, ulcers, constipation)

Yes No

Provide details:

Bladder or kidney problems (recurring infections, kidney stones)

Yes No

Provide details:

Thyroid (hypothyroidism)

Yes No

Provide details:

Diabetes in your last pregnancy

Yes No

Were you placed on insulin?

Yes No

Seizure or nerve problems (epilepsy, migraine headaches)

Yes No

Medications taken for it

History of mental illness

Anxiety or panic attacks

Yes No

Depression

Yes No

Bipolar Disorder

Yes No

Postpartum Depression

Yes No

Medications taken for it

6) Lifestyle and Social History

Are you a vegetarian or on any special diet?

Yes No

If yes, what type of diet?

Any alcohol?

Yes No

Before pregnancy

Currently

How many drinks per week?

Ever binge drink?

Yes No

Any social drug use or abuse?

Yes No

Heroine

Cocaine

Marijuana

Methadone

Crystal Meth

Ecstasy

Do you smoke?

Yes No

How many cigarettes per day?

Before pregnancy

Currently

Exposure to second hand smoke?

Yes No

Any problems with finances or housing?

Yes No

Specify

Do you have a personal vehicle or rely on public transport?

Personal Vehicle Public Transport

On social assistance? EI?

Yes No

Specify

Do you feel safe in your relationship/home?

Yes No

Please provide any details you would like to share

Date