unitedregional physician group
Patient Name: DOB:
Obstetric History Questionnaire
Are you currently pregnant? nVes i
What was the first day of your last menstrual period?.
Are your periods regular?
What is your due date if known? What is your blood type?
Are there any problems with your current pregnancy?
Prior Pregnancies:
Number of total pregnancies Number ofpregnancies carried full term (40 weeks) Number of pregnancies delivered prematurely Number of pregnancies continued past 4 months (20 weeks)
Numberof spontaneous miscarriages
Number of tubal pregnancies
Number of voluntary abortions
Number of multiple births (twins, triplets)
Number of living children
Who do you plan on using for a pediatrician?
Who is your family doctor?
Do you plan on breast feeding this child? Fill in information in table below for each pregnancy (whether the child is living or deceased). Please start with your first one. Also please list under delivery type if forceps or a vacuum were used.
Year Weeks Labor Length Birth wt. sex Type of Delivery (Vaginal or Cesarean Section) Anesthesia
Please list below any complications or comments regarding pregnancies listed above:
What is your occupation?
Are you and the father of this baby blood relatives? (Circleone) Yes No
What is the name of the father of the baby?
What is the occupation of the father of the baby?
What is the age of the father of the baby?
How would you describe the ancestry of the father of this baby? (Circle all that apply)
Caucasian French Canadian Asian African Mediterranean
Hispanic Native American Asian-East Indian Other-Southeast Asian
Hispanic Ashkenazi Jewish Middle Eastern Unknown
Is the father ofthis baby your partner? (Circle one) Yes No Do you, the father of this baby,or any close relatives have any of the following? Ifyes, please specify which relative.
Thalassemla MCV <80 • Yes • No
Neural Tube Defect (Spina Biflda or Anencephaly) • Yes nNo
Congenital Heart Defect • Yes • No
Down Syndrome • Yes • No
Tay-Sachs • Yes • No
Sickle Cell Disease or Trait • Yes • No
Hemophilia or Bleeding Problems • Yes • No
Muscular Dystrophy (Type ) • Yes • No
Cystic Fibrosis • Yes • No
Canavan Disease • Yes • No
Mental Retardation/ Autism/ Learning Disorder • Yes • No
Huntington Chorea • Yes • No
Other Inherited Genetic or Chromosomal Disorder • Yes • No
Maternal Metabolic Disorder (i.e. Insulin-dependent) • Yes • No
Patient or Baby's Father had a Childwith Birth Defects • Yes • No
Recurrent Pregnancy Loss, or Stillbirth • Yes • No
Blindness or Deafness • Yes • No
Bone or Skeletal Disorder (Dwarfism) oYes • No
Breast, Ovarian or Colon Cancer • Yes • No
Kidney Disorder • Yes • No
Diabetes • Yes • No
Blood Clots or Stroke • Yes • No
Anything else that seems to run In the family? • Yes • No Have you taken any medication other than PN vitamins since becoming pregnant?
If yes, please list.
Have you used any street drugs since becoming pregnant? • Yes • No
Have you had any exposure to any of the following?
• Sauna • Cat Litter • X-rays • Hot Tub • Chemicals • Fever/Infections/Rash • Electric Blanket
When was your last pap smear?
Have you ever had an abnormal pap? If So, When
If you have had an abnormal pap, have you ever had any of the following? (Please include date)
COLPOSCOPY LEEP CRYO THERAPY
When was your last mammogram?.
Do you plan on having an epidural?
Do you plan on permanent sterilization after having your baby? Do you have any of the following?
•Yes •No • Unsure Unexplained Fever
•Yes •No • Unsure Vision Problems
•Yes •No •Unsure Hearing Loss
•Yes • No •Unsure Ear Infections (Otherthan Childhood
•Yes •No •Unsure Sinus Problems
•Yes • No •Unsure Repeated Nosebleeds
•Yes • No •Unsure Long Term Sore Throat
•Yes • No •Unsure Pneumonia
•Yes • No •Unsure Asthma
•Yes •No • Unsure Close Contact with Person with Tuberculosis
•Yes •No •Unsure Tuberculosis Vaccine
•Yes • No •Unsure Positive Tuberculosis Skin Test
•Yes •No • Unsure Unexplained Cough
•Yes •No •Unsure Unexplained Shourtness of Breath
•Yes •No •Unsure Other Lung Problems
•Yes •No •Unsure Heart Murmur
•Yes •No •Unsure Mitral Valve Prolapse
•Yes •No •Unsure Other Heart Problems
•Yes •No •Unsure High Blood Pressure in Pregnancy
•Yes •No •Unsure High Blood Pressure Other
•Yes •No •Unsure Raynaud's Disease, Raynaud's Phenomenon
•Yes • No • Unsure Poor Blood Circulation
•Yes •No •Unsure Severe Nausea and Vomiting in Pregnancy
•Yes •No •Unsure Severe Nausea and Vomiting Before Pregnancy
•Yes •No •Unsure Intestinal Problems
•Yes •No •Unsure Unexplained Recurring Diarrhea
•Yes •No •Unsure Constipation Problems
•Yes •No •Unsure Heartburn, Reflux
•Yes •No •Unsure Hepatitis, Yellow Jaundice, Hepatitis B, C
•Yes •No •Unsure Liver Problems
•Yes •No •Unsure Bladderor Kidney Infections
•Yes • No •Unsure Kidney Stones
•Yes • No •Unsure Problem with Urine
•Yes • No •Unsure Menstral Problems
•Yes • No •Unsure Infertility, Difficulty Getting Pregnant
•Yes • No •Unsure Infertility Treatment of Assistied Reproductive Technology
•Yes •No •Unsure Vaginal Infections •Yes •No • Unsure Herpes or Apartner with Herpes
•Yes •No • Unsure Sexually Transmitted Disease
•Yes •No • Unsure Pelvic Inflammatory Disease
•Yes •No • Unsure Gonorrhea
•Yes • No • Unsure Chlamydia
•Yes • No • Unsure Syphilis
•Yes • No • Unsure Genital Warts
•Yes •No • Unsure HIV Infection, AIDS or A Partnerwith HIV/AIDS
•Yes • No • Unsure Abnormal Pap Smears
•Yes • No • Unsure Diabetes
•Yes • No • Unsure Thyroid Problems
•Yes • No • Unsure Other Hormone Problems
•Yes •No • Unsure Epilepsy, Seizure Disorder
•Yes •No • Unsure Unexplained Drowsiness
•Yes • No • Unsure Migraine/ Cluster Headaches
•Yes • No • Unsure Other Recurring Headaches
•Yes • No • Unsure Depression ( Post Partum; Major Depression)
•Yes •No • Unsure Mood Disorder/ Psychiatric/ Emotional Problems
•Yes •No • Unsure Skin Problems
•Yes •No • Unsure Unexplained Hair Loss
•Yes •No • Unsure Arthritis/ Joint Pain
•Yes •No • Unsure Lupus
•Yes • No • Unsure Rheumatic Fever
•Yes • No • Unsure Blood Transfusions
•Yes • No • Unsure BleedingTendency
•Yes • No • Unsure Blood Clots, Thrombophlebitis
•Yes • No • Unsure Rh Sensitized
Please list any other conditions not named above: History
Do vou have anv of these medical problems? If YES please circle.
Eyes - cataracts, glaucoma, glasses/contacts, macular degeneration, other Ear, Nose & Throat - allergies, sinusitis, dental abscess, swollen glands. Chronic sore throat, TMJ Heart - high blood pressure, irregular heart beat, heart failure, heart attack, CAD Lungs - asthma, emphysema, CORD, pneumonia, sleep apnea, cancer Stomach & Intestines - reflux, ulcers, irritable bowel, diverticulosis, constipation, cancer Urinary - urine incontinence, prostate disease, sexuallytransmitted disease, kidney stones Muscles & Joints - arthritis, pain in arms/legs/neck/back, radiating pain Brain & Nerves - seizures, headache, migraines, stroke, Parkinsonism, dementia Skin - acne, eczema, psoriasis, hives, cancer, other: Hormones - diabetes, thyroid, high cholesterol, menopausal, osteoporosis, gout Blood - anemia, bleeding, blood clots, cancer Psychiatric - depression, anxiety, bipolar, schizophrenia, other:
Please list any other medical issues you have currently not listed above.
Have vou had anv surgeries? If YES, please list below Surgery Age Physician Year
Please list any other medical providers involved in your care:.
Are vou currentiv taking anv medicines? If YES please list below, or provide a current list
Name of Medication Medicine dose How many times each day? For what condition? Are vou allergic to any medications? If YES please medication and reaction below
1. 2. 3.
4. 5. 6. 'V Pharmacy of Choice.
Familv^s Medical History
Maternal Maternal Paternal Paternal Mother Father Sister Brother Grand Grand Grand Grand Mother Father Mother Father
Alcoholism
Anxiety
Arthritis
Asthma
Cancer & Type
Depression
Diabetes
Heart Disease
Hyperlipidemia
Hypertension
Kidney Disease
Osteoporosis
Seizures
Stroke Thyroid Disease
Social History Information Are you adopted? (Y/N) Doyou have children? (Y/N)
Tobacco Use: Current Former Never Type Units per day. Duration
Alcohol Use: Current Former Never Type Units per day. Duration
Caffeine Usage Daily. Type.
Do you have an Advance Directive? (Y/N ) OOj • :PERSOMAt;i{ilFpRM srf 1 f '.t 1 ^ Y, . rl'.l Pallcnl Name jOate of Bii-tn Age Gondof (M/P) • Toda/j Data (M(VOO/YY) Health Cars Provldor Instructions: This is a screening tool for cancers that run in families. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. Next to each statement, please list the reiationship(s) to you and age of diagnosis for each cancer in your family. You and the following close bood relatives should be considered: You. Parents. Brothers, Sisters, Sons. Daughters, Grandparents,Grandchildren, Aunts, Uncles, Nephews, Nieces, Half-Siblings, First-Cousins, Great-Grandparents and Great-Grandchildren WU; , RARENTS/SlBgl^^lg^oof ' Diagnosis OY Breast cancer ON (Female or Male) OY Ovarian cancer ON (Peritoneal/Fallopian tube) 0 Y Endometriai (.Uterine) • ON cancer Colon/rectal cancer 10 or more Lifetime Colon/ Rectal Polyps (Specify F) Among othart. conild*r th« following eancftrs; l>tel»nonu, Pancrcadc. Stomach (Gastric). Brain, Kidney, Bladder. Small bowel. Sarcoma, Thyroid, Prostate O Y Other Cancer(s) ON (Specify cancer type) OY ON Are you of Ashkenazi Jewish descent? OY ON Are you concerned about your personal and/or family history of cancer? OY Have your or anyone in your family had genetic testing for a hereditary cancer syndrome? (Please explain/include a copy of result If possible) • 0 N If Yes. Who? What aenfir.sl? What was the result? What age were you when you started your first period? Age at the time of your first birth: Have you ever had breast biopsies done? YES/NO Haveyou gone through menopause? At what age did you enter menopause?, z 0 Have you everused hormone replacement therapy orare you currently on hormonerepiacement therapy? YES/ NO 1 If so, for how long? years Hpw many sisters do you have? How manysistersdid yourmotherhave?(Maternal aunts) How manysistersdidyourfather have? (Paternal aunts), >-z oo "This questionnaire will be reviewed by a provider within United Regional You and your physician will bo contacted if you meet national criteria for genetic evaluation, if OYES you choose or your physician requests, you will be offered a consultation appointment to discuss the history provided. Please Indicate if you DO or DO NOT consent to this provider review. |U INU Signature Oats 1 Patient's Signature Oato Hftalcn Care Provider's Signature Date