OB Medical History - Southwest Midwives

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Please complete this patient information survey to the best of your knowledge & ability. Please leave any sections blank if you are unsure or uncomfortable answering. The purpose of these questions is to recognize a holistic range of factors which may affect your care, and to help us identify and meet your individual health needs. This survey will become part of your confidential medical record. Thank you!

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All data submitted through this form electronically will be treated in accordance with our privacy policy and will be encrypted and stored securely.

PERSONAL INFORMATION

Patient Name *

First

Last

Date of Birth *

Age *

Email *

What is your relationship status (single, married, divorced, partnered, etc.)?

Occupation (job, student, stay-at-home mom, etc.)?

Living situation: who shares your home (roommates, husband & kids, dogs/cats, etc.)?

CURRENT PREGNANCY

1st day of last menstrual period:

Are you certain of this date?

Length of Menstrual Cycle: Every __ days (measured from 1st day of one period to 1st day of next period; i.e. every 28 days or 21-38 days if irregular)

Pre-pregnancy weight (lbs)

Height (ft and inches)

Were you on birth control or breastfeeding at the time of conception?

Have you had any ultrasound during this pregnancy?

Was this pregnancy planned?

If you considering termination or adoption please explain.

Please note below if this pregnancy was conceived with fertility treatment (ie. Clomid, IVF), donor eggs or sperm, or if you are a surrogate or gestational carrier.

Name of Father of Baby & Relationship to you:

Do you or the baby's father have any personal history or blood relatives with the following conditions (check all that apply):

Cleft lip/palate
Cystic fibrosis
Congenital heart defect
Muscular dystrophy
Neural tube defect (spina bifida)
Tay-Sachs or Ashkenazi Jewish ancestry
Autism
Hemophilia
Deafness
Thalassemia
Sickle cell
Developmental delays
Chromosome disorders
Stillbirth
Huntington’s
Other known genetic disease

MEDICAL HISTORY

Do you have any allergies? *

Please list any allergies (latex, medications, foods, etc.)

Are you currently taking any prescriptions, vitamins, supplements? *

Please list all current prescription medications, as well as any vitamins/supplements you use on a regular basis.

Approximate date and location (please specify name of medical office/facility) of your last Pap (write NA if you have never had a pap)?

Please list any surgeries you have had & approximate year of procedure.

Have you had any hospital admissions other than for surgeries listed above, or childbirth?

Please provide details of other hospital admissions you have had in the past.

Please indicate below if you or your blood relatives (parents, grandparents, siblings, children, aunts/uncles) have been affected by the following conditions (check all that apply):

Thyroid disease (ie. Hashimoto, Graves)
Hypertension (high blood pressure)
Diabetes (including gestational diabetes)
Preeclampsia
Mental illness (including depression, anxiety, eating disorder, postpartum depression, PTSD)
Blood clot (DVT, PE
Seizures
Preterm delivery (<37 wk)
Twin or multiple pregnancy
Autoimmune disease (ie lupus, MA, RA)
Kidney disease
Liver disease (including hepatitis)
Heart disease (ie. heart attacks, bypass surgeries, arrhythimia)
Stroke
Thrombophilia (ie. Factor V Leiden)
Cancer

For all conditions that are selected above please provide who, age of onset, and any additional notes.

Please indicate if you have/had the following (check all that apply):

Asthma
Eczema or Psoriasis
Blood Transfusion
Kidney Stones
Fibroids
Genital Herpes
Abnormal Pap
Chickenpox
Migraines
GI Disease: GERD, IBS, pancreatitis, or IBD (Crohns, colitis)
Chronic pain or Fibromyalgia
Recurrent (>2 infections per year): UTI, Yeast, or BV
Gallbladder stones and disease
HPV Vaccine
PCOS
Varicella vaccine

Have you had any other STI's (Chlamydia, gonorrhea, trich, HIV, syphilis) or PID?

Yes
No
Don’t know

Did you have a colposcopy, cryotherapy, LEEP, or conization?

Yes
No
Don’t know

Have you had other medical issues? Any notes to include on entries above?

Did you have this year's seasonal flu vaccine?

Would you accept a blood transfusion if it was necessary?

Please note any dietary restrictions (ie. vegetarian, vegan, gluten-free, Kosher, etc.)

SOCIAL HISTORY

Indicate the highest level of education you have completed.

Some high school
High school diploma
Some college
Undergraduate degree
Graduate degree

Do you currently, or have you ever, smoked cigarettes regularly?

What age did you begin smoking?

How much do you currently smoke?

If you quit smoking, when did you quit?

Do you currently use marijuana?

Have you used alcohol since becoming pregnant?

Have you used other drugs besides marijuana since becoming pregnant?

Have ever had a substance use disorder?

Did you ever seek help (ie. AA/NA program, opioid treatment, etc.)?

Have you ever experienced domestic violence, sexual assault, or abuse?

Do you currently feel safe in your home?

If you have children, do you have full custody of your children?

Do you belong to a religious community, tribe, otherwise hold cultural/spiritual beliefs which might affect your care?

Please provide more information about the beliefs that might affect your care.

Please note any additional information about your responses in this section.

OBSTETRIC HISTORY

Have you had any miscarriages?

Yes
No
Don’t know

Have you ever terminated a pregnancy (had an abortion)?

of Have birth

Have you ever had an ectopic pregnancy?

Yes
No
Don’t know

Have you ever had a molar pregnancy?

Yes
No
Don’t know

Have you given birth previously?

For each birth you have had previously, please provide the requested information below.

1st Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)

2nd Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)

3rd Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)

4th Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)

Additional Births-Please note name(s), birth date(s), sex, gestation age(s) (# weeks pregnant), labor length(s), delivery type(s) (vag or C/S), delivery weight(s), and birth location(s) (city, state, home birth, etc.)

Were forceps or vacuum used with your delivery or deliveries?

Are all of the children you gave birth to currently living?

Do all of your children who you have given birth to have the same father?

If you had a C-section: Please note why it was done if you know the reason.

Are you interested in learning more about a VBAC (vaginal birth after Cesarean)?

Please note if you had any complications with previous deliveries (i.e. postpartum hemorrhage, shoulder dystocia, 4th degree tear, placental abruption, etc.)

ADDITIONAL INFORMATION

How did you hear about Southwest Midwives? (If you heard of us through a friend or relative, please share the name of the person who referred you!)

Is there anything else you would like us to know, or to address with you at our first meeting?