Name *

First Name

Last Name

Birthing Person's Date of Birth

MM

DD

YYYY

Partner's Name (if applicable)

First Name

Last Name

Partner's Date of Birth

MM

DD

YYYY

Family History

To the best of your knowledge, has anyone in your immediate family ever had any of the below? If yes, who and when?

High Blood Pressure

Heart Attack

Diabetes

Twins

Birth Defects

Cancer

Mental Illness

Substance Abuse

Tuberculosis

Other

Father of Baby (FOB)

Has the father of this baby ever had any of the below?

Sexually Transmitted Infections (STI's)

Genital or Oral Herpes

Mental Illness

Substance abuse

Tobacco Use

Have you or the FOB ever had a baby with a birth defect of any kind?

Yes

No

Do you or the FOB have any family members with birth defects or genetic conditions of any kind?

Yes

No

Are you or the FOB from any of the following groups?

Ashkenazi

Jewish

Asian

Mediterranean

Do you think you are at an increased risk for having a baby with a genetic problem?

Yes

No

Your Medical History

If you have had any of the following below or condition not listed, please check & indicate when/treatment in the space below.

Severe Headaches

Pelvic or back injury

Ulcers

Hemorrhage

Hemorrhoids

Skin Disorders

Bowel Problems

Diabetes

Kidney Infection(s)

Recurrent UTI(s)

Seizures

Surgeries

Vision Problems

Thyroid (hypo/hyper)

Heart Problems

Hypertension

Tuberculosis

Liver Problems

Hypoglycemia

Arthritis

Cancer

Blood Transfusions

Anemia

Varicose Veins

Asthma

Blood Clotting Disorder

Chicken Pox

Hepatits

Dental Problems

Hospitalization

Other

Pain and/or cramping?

Yes

No

Please indicate if you have ever had any of the following.

Yeast Infections

Bacterial Vaginosis

Syphilis

Herpes: Oral or Genital

Cervical Surgery

Fibroids

Uterine Surgery

Breast Lumps

Gonorrhea

Abnormal Bleeding

Cervicitis

Ovarian Cyst

Fertility Problems

Trichomonas

Chlamydia

PID/Pelvic Infection

HPV or Genital Warts

Cervical Polyp(s)

Endometriosis

Group B Strep

Genital Sores

Breast Surgery/Augmentation

Other

Suspected Date of Conception

MM

DD

YYYY

Date of positive pregnancy test

MM

DD

YYYY

First day of last period?

MM

DD

YYYY

Are you sure of last period date?

Option One

Option Two

Was it a normal period?

Yes

No

Is this a planned pregnancy?

Yes

No

Have you had any of the following during this pregnancy?

Nausea

Vomiting

Fever

Infection(s)

Headaches

Dizziness

Indigestion

Leg Cramps

Rash

Backache

Diarrhea

Constipation

Swelling

Non-Food Cravings (PICA)

Urinary complaints

Abdominal pain

Vaginal bleeding

Vaginal discharge

Bleeding gums

Varicose veins

Hemorrhoids

Depression

Loneliness

Work problems

Family/relationship problems

Other

Have you used, experienced, or been exposed to any of the following this pregnancy?

Tobacco

Alcohol

Raw Meat

Marijuana

Cocaine

Opiates

Caffeine

Herbs

Prescription drugs

Vitamins

Ultrasound

X-Ray

Fumes/Pesticides

Lead

Mercury

Measles

Vaccinations

Cats

Travel