OBSTETRICAL VISIT

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Date    
First Name Last Name 
Social Security Number    
Primary Care Physician
Insurance Company Insurance Number
Final Est. Due Date Delivery Hospital 
Newborn's Physician Referred By 
Birth Date (DD/MM/YY) Age 
Marital Status  S M W D SEP Race 
Education (Last Grade Completed)
Occupation

Contact Information
Street Address
City State Zip
Home Phone Other Phone    
           
Husband/Father of Baby His Phone 
Emergency Contact Name Contact Phone 

Menstrual History
Date of Last Menstrual Period Exact Approx. (month known) Unknown Final
Do you Menstruate Monthly? Yes No
Length in days     
Age of first Menstrual Period
Were you taking birth control pills at conception? Yes No
Was your pregnancy test positive? Yes No

Pregnancy History
Total Pregnancies Full Term Premature
Miscarriages Abortions Tubal Pregnancies
Multiple Births Living Children  

Past Pregnancies (last six)
No. Date
M/Y 		GA
Weeks		 Length
of Labor		 Birth
Weight 		Sex Delivery
Type		 Anes Delivery
Location		 Preterm
Labor
1. M F Yes No
2. M F Yes No
3. M F Yes No
4. M F Yes No
5. M F Yes No
6. M F Yes No
 
Comments / Complications (please specify which pregnancy)

Past Medical History

    
Condition Positive / Negative Condition Positive / Negative
Diabetes Pos Neg D (Rh) Sensitized Pos Neg
Hypertension Pos Neg Pulmonary (TB. Asthma) Pos Neg
Heart Disease Pos Neg Allergies (Drugs) Pos Neg
Autoimmune Disorder Pos Neg Breast Pos Neg
Kidney Disease / UTI Pos Neg Gyn Surgery Pos Neg
Neurologic / Epilepsy Pos Neg Operations, Hospitalizations Pos Neg
Psychiatric Pos Neg Anesthetic Complications Pos Neg
Hepatitis / Liver Disease Pos Neg History of Abnormal Pap Pos Neg
Varicosities / Phlebitis Pos Neg Uterine Anomaly / DES Pos Neg
Thyroid Dysfunction Pos Neg Infertility Pos Neg
Trauma / Domestic Violence Pos Neg Relevant Family History Pos Neg
History of Blood Transfusion Pos Neg Other Pos Neg
 
Please provide details of Positive Remarks above (including date & treatment)
 
  Amount per Day
Pre-Pregnancy 		Amount per Day
During Pregnancy 		Number of
Years Using 		 
Tobacco  
Alcohol  
Street Drugs  

Comments

      

 
 
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