|
Date Form Completed:
|
|
|
Personal Health History
|
|
|
Allergic reaction to a medication or vaccine component?
|
If yes, please list
|
|
Any other allergies or reactions?
|
|
|
Condition that you have or have had in the past:
• • •
|
Other
|
|
Describe, if needed
|
|
|
Please indicate any surgery or hospitalization that you have had and the date:
|
|
|
Please describe any health problems or symptoms that you are having at this time:
|
|
|
Have a history of problems with anesthesia?
|
If yes, please describe?
|
|
Objections to any form of medical treatment?
|
If yes, please describe?
|
|
Do you smoke?
|
If yes, how many packs per day?
|
|
If former smoker/user, when did you quit?
|
|
|
Do you consume alcohol?
|
Indicate number of drinks per week
|
|
What type of drinks?
|
|
|
Medications taken since your last period
|
|
|
Used street drugs since your last menstrual period
|
Indicate number of uses per week
|
|
What type of drugs?
|
|
|
Reason to believe you/partner may have been exposed to HIV/AIDS?
|
|
|
Exposed to chemicals since you became pregnant?
|
If yes, please describe?
|
|
Are you on a restricted diet?
|
If yes, please describe?
|
|
Gynecologic Health History
|
|
|
When was your last Pap test?
|
|
|
Received all 3 doses of the HPV vaccine?
|
|
|
Ever had an abnormal pap test?
|
If yes, when and how were you treated?
|
|
What was the diagnosis?
|
|
|
Have you ever had HPV?
|
|
|
Have you ever had
• • •
|
|
|
If yes, when, how, and where were you treated?
|
|
|
Have you ever had herpes?
|
If yes, where do you have outbreaks?
|
|
If yes, how often do you have outbreaks?
|
|
|
Have you ever had syphilis?
|
If yes, how, when, and where were you treated?
|
|
Used an intrauterine device (IUD) for contraception?
|
If yes, please indicate when:
|
|
Did you have any problem with the IUD?
|
If yes, please describe?
|
|
Have you been treated for infertility?
|
If yes, please describe when and treatment received
|
|
Concerns related to your past health history?
|
If yes, please list
|
|
Family History & Genetic Screening
|
|
|
What is your ethnicity?
|
What is the ethnicity of the baby’s father?
|
|
You/baby’s father had a child born with a birth defect?
|
If yes, please describe?
|
|
You/baby’s father have a birth defect?
|
If yes, please describe?
|
|
Describe any special needs that have occurred in children of your family or the baby’s father’s family
|
|
|
How is this child/person related to you?
|
|
|
You/baby’s father have a history of pregnancy losses?
|
Either of you had genetic counseling?
|
|
Either of you had chromosomal testing?
|
Where and what were the results?
|
|
You are, or the baby’s father is, of one of these backgrounds:
|
|
|
Eastern European Jewish (Ashkenazi) Ancestry
|
If yes, had tay–sachs screening tests?
|
|
If yes, had a canavan screening test?
|
|
|
Had familial dysautonomia screening?
|
|
|
Date:
|
Result
|
|
African American
|
|
|
If yes, had sickle cell screening?
|
|
|
Date:
|
Result
|
|
Mediterranean Ancestry or Southeast Asian Ancestry
|
|
|
Had screening for inherited forms of anemia such as Thalassemia?
|
|
|
French Canadian or Cajun Ancestry
|
|
|
If yes, had tay–sachs screening tests?
|
|
|
Have you had cystic fibrosis screening?
|
|
|
Had any other genetic carrier screening?
|
Screening
|
|
Date:
|
Result
|
|
Please list any other concerns you have about birth defects or inherited disorders:
|
|
|
Test that will tell about risk to have a baby with Down syndrome?
|
Is the father 45 years or older?
|
|
Psychosocial Screening
|
|
|
Have problems that prevent from keeping health care appointments?
|
Do you feel unsafe where you live?
|
|
Exposed to second-hand smoke?
|
In past 2 months, used any form of tobacco?
|
|
In the past 2 months, have you used drugs or alcohol?
|
In the past year, threatened/hit/slapped/kicked by anyone?
|
|
Forced you to perform sexual act that you did not want?
|
|
|
Rate your current stress level?
|
|
|
How many times have you moved in the past 12 months?
|
|
|
If you could change the timing of this pregnancy, would you want it
|
|
|
Notes
|
|
