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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