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New Pregnancy Visit

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Current Medications (include hormones, herbs, vitamins, nonprescription medicine)

Current Medications (include hormones, herbs, vitamins, nonprescription medicine)

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Allergies (please include all drug allergies)

Allergies (please include all drug allergies)

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What is your problem today: late of menses, irregular menses, abnormal uterine bleeding, positive home pregnancy test, negative home pregnancy test

What is your problem today: late of menses, irregular menses, abnormal uterine bleeding, positive home pregnancy test, negative home pregnancy test

Have you used the pill Depo-Provera recently?
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Was your last period normal?
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Was your last period normal?
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Any problems thus far this pregnancy?
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Since Your Last Visit:

Since Your Last Visit:

Have you been diagnosed with a new medical problem?
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Have you had any surgeries?
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Have you been diagnosed with a new medical problem?
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Do you have any new family history?
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Menstrual History

Menstrual History

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Are your periods regular (28-30 days)?
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Do you have pain with your period?
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Choose “YES” or “NO” on each of the following. If “YES”, please list which side of the family (Maternal or Paternal?), which relative, is it your family member or father of the baby’s family member, is it you or the father of the baby?

Choose “YES” or “NO” on each of the following. If “YES”, please list which side of the family (Maternal or Paternal?), which relative, is it your family member or father of the baby’s family member, is it you or the father of the baby?

1) Thalassemia (inherited blood disorders. “Inherited” means passed from parents to children through the genes; Mediterranean region):
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2) Neural tube defect (an opening in the spinal cord or brain):
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3) Congenital heart defect (a defect in the structure of the heart and great vessels):
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4) Down Syndrome:
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5) Tay-Sachs (autosomal recessive genetic disorder):
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6) Canavan disease (autosomal recessive [2] degenerative disorder that causes progressive damage to nerve cells in the brain):
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7) Familial Dysautonomia (a disorder of the autonomic nervous system):
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8) Sickle cell disease or trait:
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9) Hemophilia or blood disorders:
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10) Muscular dystrophy:
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11) Cystic fibrosis:
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12) Huntington’s chorea (a neurodegenerative genetic disorder that affects muscle coordination and leads to cognitive decline and dementia):
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13) Mental retardation:
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14) Autism:
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15) Other inherited genetic chromosomal disorder:
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16) Maternal metabolic disorder (Type I diabetes, PKU, etc.):
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17) Have you or your family members, or father of the baby’s family members, had a child with birth defects not listed above?
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18) Recurrent pregnancy loss, or a stillbirth:
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19) Do you live with someone with TB or have you been exposed to TB?
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20) Do you or your partner have a history of genital herpes?
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21) Have you had a rash or viral illness since your last period?
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22) Do you or your partner have Hepatitis B or C?
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Choose “YES” or “NO” if you or your partner have now ( or have ever had) the following:

Choose “YES” or “NO” if you or your partner have now ( or have ever had) the following:

Chlamydia
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Syphilis
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HIV/ AIDS
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Gonorrhea
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Genital Warts
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Pubic lice or crabs
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Human Papilloma Virus (“HPV”)
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Trichomoniasis (“Trich”)
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