New OB Patient History
The Basics:
Name: ______
Home phone #:______
Cell phone #: ______
Father of the Baby:
______
□ Husband □ Domestic Partner
Years married / together? ______
Emergency Contact Person:
______
Relationship to you:
______
Emergency Contact Phone #:
______
Background Information:
Youroccupation:
______
Your Job Title:
______
Father of the Baby’s occupation:
______
Father of the Baby’s Job Title:
______
Your Race:
______
YourCountry of birth:
______
Your primary language spoken:
______
Your Religion:
______
Drug Allergies?yesno
Explain______
Are you allergic to latex?yesno
Food allergies?yesno
Pre-pregnancy weight: ______
Current Medications: ______
______
Education:
Last Grade Level Completed:
□ High School
□ College
□ Post Grad
Did you have any special education needs in school?yesno
How do you learn best?
□ Listening / watching
□ Demonstration
□ Reading
Are you enrolled in any of the following?
WICyesno
Food Stampsyesno
Families First AFDCyes no
Social Securityyesno
How many meals do you eat in a day?
______
Do you have an advanced directive?
yesno
Do you want information about an advanced directive [living will]?
yesno
Do you have any spiritual or cultural needs that would effect how we care for you? yes no
Explain:______
Do you have any objections to receiving blood products?yesno
Do you live in a:
□ House
□ Apartment
□ Other______
Where you live do you have the following?
Electricityyesno
Wateryesno
Well wateryesno
Cooking facilities / kitchen
yesno
Stairsyesno
What is your current form of transportation?
□ Personal vehicle
□ Family and friends
□ Public transportation
□ TennCare transportation
Planning for your baby?
Do you have an infant car seat?
yesno
How do you want to feed your baby?
□ Breast and Bottle
□ Breast only
□ Bottle only
□ Not sure
If your baby is a boy, do you want him circumcised?yesno
When you deliver your baby, what type of pain medication do you want?
□ Epidural
□ IV Medicine
□ None
What type of birth control do you want to use after your baby is born?
□ Pills
□ Depo Provera Injections
□ IUD
□ Permanent Sterilization
□ Unsure
Will your baby be placed for adoption?
yesno
Do you have a birth plan?yesno
GYN History
Do you have your menstrual cycle every 28 – 30 days?yesno
If not, how often? ______
What was the first day of your last menstrual period? ______
How was your pregnancy confirmed?
□ Home pregnancy test
□ Doctor’s office/clinic test
Medical History & Health Maintenance
Do you exercise regularly?yesno
Are your immunizations up to date?
yesno
Do you drink alcoholic beverages?
yesno
Do you use street drugs?yesno
Do you smoke?yesno
Past Pregnancies (please use another sheet of paper if you need more room)
Pregnancy # / 1 / 2 / 3 / 4Month/Year of Birth
Male / Female
Birth weight
Vaginal birth,
c-section, miscarriage, or abortion
Pain Management
Feeding Breast or Bottle
Childs Name
Weeks at time of delivery
Hours in labor
Problems?
Medical History and Health Maintenance / Patient / Family / Unsure
Multiple Births [i.e. twins] / Yes / No / Yes / No
Malignancies [i.e. cancer] / Yes / No / Yes / No
Hypertension [i.e. high blood pressure] / Yes / No / Yes / No
Heart Disease / Yes / No / Yes / No
Pulmonary Disease [i.e. asthma] / Yes / No / Yes / No
GI Problems [i.e. crohn’s disease] / Yes / No / Yes / No
Breast Disease / Yes / No / Yes / No
Urinary tract problems [including UTI’s & Pyelo] / Yes / No / Yes / No
Endocrine/Metabolic [i.e. diabeties/thyroid] / Yes / No / Yes / No
GYN problems / Yes / No / Yes / No
Abnormal pap smears / Yes / No / Yes / No
Fibroids / Yes / No / Yes / No
Abnormal uterine bleeding / Yes / No / Yes / No
Incompetent cervix / Yes / No / Yes / No
Other: ______/ Yes / No / Yes / No
Infertility/recurrent miscarriage / Yes / No / Yes / No
STD’s, HPV, Group B Strep, Herpes / Yes / No / Yes / No
Phlebitis/varicosities
[i.e. varicose veins, blood clots] / Yes / No / Yes / No
Neurological [i.e. seizures] / Yes / No / Yes / No
Psychiatric [i.e. depression] / Yes / No / Yes / No
Immunologic/infectious disease
[i.e. Lupus or HIV] / Yes / No / Yes / No
Operations/ accidents / Yes / No / Yes / No
Hematologic [i.e. Anemia] / Yes / No / Yes / No
Other hospitalizations:
______/ Yes / No / Yes / No
History of sexual or physical abuse / trauma / Yes / No / Yes / No
Genetics: Mother & Father
and Your Families History / Patient / Family / Unsure
Patient age >34 at delivery / Yes / No / --- / ---
Thalessemia; MCV < 80 / Yes / No / Yes / No
Neural Tube Defect / Yes / No / Yes / No
Congenital Heart Defect / Yes / No / Yes / No
Down Syndrome / Yes / No / Yes / No
Jewish, Cajun, French Canadian [tay sachs] / Yes / No / Yes / No
Jewish: Canavan Disease, Gauchers / Yes / No / Yes / No
Sickle Cell Disease [African American or Caribbean] / Yes / No / Yes / No
Hemophilia or other blood disorders / Yes / No / Yes / No
Muscular Dystrophy / Yes / No / Yes / No
Cystic Fibrosis / Yes / No / Yes / No
Huntington’s Chorea / Yes / No / Yes / No
Mental Retardation / Autism [if yes was it fragile x? ______] / Yes / No / Yes / No
Other inherited or chromosomal disorder / Yes / No / Yes / No
Other structural birth defect / Yes / No / Yes / No
Maternal metabol/endocrine disorders [diabetes, PKU] / Yes / No / Yes / No
Patient or baby’s father had a birth defect not listed above:
______/ Yes / No / Yes / No
Recurrent pregnancy loss [>2] and/or stillbirth / Yes / No / Yes / No
Tobacco, Alcohol, Drugs / Yes / No / Yes / No
Any other:
______/ Yes / No / Yes / No
VanderbiltCenter for Women’s Health – phone 615-343-5700 / fax 615-343-6724
One Hundred Oaks – 719 Thompson Lane, Suite 27100, NashvilleTN37204
Cool Springs – 2009 Mallory Lane, Suite 230, Franklin TN 37067
Clarksville – 647 Dunlop Lane, Suite 206, Clarksville, TN37040