Past History Form

Patient Name:

Date of Birth:

Gender:

Male Female

Mother's Past Medical History

A. Pregnancies?

Yes No

B. Live Birth?

Yes No

C. Miscarriages?

Yes No

(For child birth to age 3)

A. Length of Pregnancies?

B. Complications During Pregnancy:

High Blood Pressure?

Yes No

Infection?

Yes No

Bleeding

Yes No

Other?

Yes No

C. Labor?

Induced Spontaneous

D. Length of Labor?

E. Type of Labor?

!. Normal 2. Breech 3. C-Section

(Please fill in all apply.)

A. Newborn Weight?

B. Newborn Length?

C. Length of hospital stay?

D. Any complications in the first Month of Life?

E. Allergies?

F. Was this patient born at Tomball Regional Hospital?

G. Accidents?

H. Operations?

I. Hospitalizations?

J. Illness?

K. Development up to date in school?

(Ever been retained a grade?)

Mother's Age:

Father's Age:

Any Questions or Concerns.