OB/GYN PATIENT HEALTH HISTORY QUESTIONNAIRE
OBSTETRICAL HISTORY INCLUDING ABORTIONS & ECTOPIC (TUBAL) PREGNANCIES Year Place of Delivery or Termination Duration Pregnancy Hours of Labor Type of Delivery (Child) Sex (Child) Birth Weight (Child) Present Health Note Complications Mother and/or Infant • Preeclampsia • Gestational Diabetes • Premature Labor • Other / Specify D BIRTH ... ................
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