General Health Information

GENERAL HEALTH INFORMATION

Do not leave anything blank. If the question does not apply to you, please write N/A (not applicable).

Name______Date of Birth______

Social Security Number______Pregnancy Due Date______

Are you on a special diet?______If so, explain______

Are you taking any medication?______If so, list ______

Are you allergic to any drugs?______If so, list______

Are you allergic to any foods?______If so, list______

Do you have any other allergies______If so, list______

Explain symptoms of allergies and reactions______

What precautions and treatments do you use for your allergies?______

Have you ever:

Been hospitalized? Yes______No______If yes, explain______

Had any surgery? Yes______No______If yes, explain______

Worn glasses or contacts? Yes_____ No_____ Date of Last Exam ______

Had any dental problems? Yes______No______If yes, explain______

When was your last dental exam?______

Have you ever had any of the following? Please circle if yes.

Eye infectionsLiver DiseaseDepression

Thyroid DiseaseDiverticulitisChildhood Hyperactivity

Hives or RashesHerniaGerman Measles

BronchitisHemorrhoidsMeasles

PneumoniaScarlet FeverRheumatic Fever

MumpsPolioMental Illness

MononucleosisSTD’sChicken Pox

NarcolepsyAnorexiaBulimia

Hepatitis AHepatitis BHepatitis C

AnemiaShinglesSeizures

TB

Please write below any additional medical information we should know.

Do you have any complications that resulted from childhood diseases?

Do you smoke cigarettes? Yes______No______(Please note Hannah's House has a no smoking policy.)

Have you consumed alcohol or used drugs since your pregnancy?

Yes______No_____Before your pregnancy? Yes______No______

If so, what did you use?______

How often?______

How much?______

Tests and Immunizations: Please check those you have had and the year you were given the test or immunization.

(Year) (Year)

_____(______) Chest x-ray_____(______) Tetanus shots

_____(______) Gastro-Intestinal series_____(______) Polio series

_____(______) Electrocardiogram_____(______) Flu shots

_____(______) TB test_____(______) MMR shots

_____(______) Smallpox shots_____(______) HIB shots

_____(______) Tdap

Have you had any previous pregnancies? If so, please list the dates.

Live Births ______Miscarriages______Abortions______Other ______

Who should we contact in case of emergency?

Name______Relationship to you?______

Address______City______State ______Zip______

Phone(s) Home ______Work ______Cell ______

Email ______

Name______Relationship to you?______

Address______City______State ______Zip ______

Phone(s) Home ______Work ______Cell ______

Email ______

Family History

Please give us the following information about your family.

Mother’s Name______

Address______City______State ______Zip ______

Phone(s) Home ______Work ______Cell ______

Place of Employment______

Church Affiliation (if any)______

Marital Status______

Any additional information you would like to share with us______

______

Father’s Name______

Address______City______State ______Zip ______

Phone(s) Home ______Work ______Cell ______

Place of Employment______

Church Affiliation (if any)______

Marital Status______

Any additional information you would like to share with us______

______

Please list your brothers and sisters, including in-laws, and their ages.

______

Please give us the following information about your baby’s biological father.

Father’s Name______

Address______City______State ______Zip ______

Phone(s) Home ______Work ______Cell ______

Email ______

Place of Employment______

Church Affiliation (if any)______

Marital Status______

Any additional information you would like to share with us______

______

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