PREGNANCY HISTORY QUESTIONNAIRE



PREGNANCY HISTORY QUESTIONNAIRE-Ultrasound

Name:_____________________________________ Age:___________ DOB:_______________

Current Weight____________ Height_____________ Ethnicity_______________________

Referring OB/Gyn or Clinic Name:______________________________________________

Will you be 35 or older at time of delivery? Y N

What was the 1st day of your last period?____________

If Unknown; what is your due date?______________

Have you had any previous ultrasounds during this pregnancy? Y N

Did you have IVF/IUI? Y N If yes, Did you have ICSI? Y N

PREGNANCY HISTORY: Please list ALL pregnancies.

How many times have you been pregnant INCLUDING this pregnancy?__________

How many children do you have?________ Any prior C-sections? Y N If so, how many?_______

Any miscarriages? Y N If so, how many?______ Was a D&C performed? Y N

Any terminations? Y N If so, how many?_______

Have you ever had a stillbirth or baby that died? Y N If so, please explain_______________

Have you had any preterm deliveries? Y N If so, how many weeks were you?_____________

Have you ever had a child or pregnancy diagnosed with ANY type of abnormality or

defect? Y N If so, please explain__________________________________________

Is there any other family history of birth defects, chromosomal abnormalities, or mental retardation? Y N If so, please explain_______________________________________

Do you have a history of LEEP, Cone Biopsy, or procedure to your cervix ? Y N If so what procedure did you have?____________ When?__________

Do you have a history of a cerclage(stitch to your cervix during pregnancy)? Y N

Any history of uterine surgery, such as myomectomy? Y N

The following questions are regarding your CURRENT PREGNANCY

Have you had any vaginal bleeding during this pregnancy? Y N

Have you had any abnormal test results during this pregnancy? Y N (For example: 1st trimester screening, quad screen, or AFP) If so, please explain___________________________________

MEDICAL HISTORY: Do you PERSONALLY have past or present any of the following:

DIABETES/GESTATIONAL DIABETES HIGH BLOOD PRESSURE BLOODCLOTS/STROKE

KIDNEY/LIVER/HEART DISEASE BLOOD DISORDER BIRTH DEFECT

LUPUS/AUTOIMMUNE DISORDER HYPO/HYPER THYROID HIV/AIDS

THALASSEMIA/SICKLE CELL TRAIT Any Other Illness______________________________

Do you take any prescription or over the counter medications other than prenatal Vitamins? Y N If so, please list:________________________________________________________________

PHYSICIANS ARE EMPLOYED BY RUTGERS UNIVERSITY MEDICAL SCHOOL

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