Gynecology & Obstetrics | Manhattan, KS

NEW OB QUESTIONARE

New OB Questionnaire

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First name

Last name

Middle name

Date of Birth

Email address

Mobile Phone number

Father of baby:

Father's contact information

Father's relationship to the patient

Who will be your pediatrician for the baby?

Do you have any drug allergies

Yes

If yes, what is your reaction?

First day of your last period

Is this definitive or best guess?

Prior to this pregnancy, did you have a period monthly?

If so, how many days from one period to the next?

How old were you when you first got your period?

What is the first day of your period PRIOR to your last period?

Were you on birth control at the time you conceived this pregnancy?

Please list any chronic medical conditions or illnesses:

Please list all medications (to include prenatal vitamins):

Do you have any drug allergies?

Yes

Option 2

If yes, what is your reaction?

Have you already received care for this pregnancy

Free Text

Pregnancy Screening Questions: For the following questions, please indicate if the question applies to either you (self), father of the baby (FOB), both, or none.

Interested in non-invasive prenatal testing?

Neural tube defect (meningomyelocele, spina bifida, or anencephaly)

Congenital heart defect

Down Syndrome

Tay-Sachs (Jewish, Cajun, French-Canadian)

Sickle cell disease or trait

Hemophilia or other blood disorder

Cystic fibrosis

Interested in cystic fibrosis testing?

Intellectual disability or Autism

If yes, was the person tested for Fragile X?

Huntington's Chorea

Maternal metabolic disorder (Type 1 diabetes, PKU)

Have either of you had a previous child with a birth defect not listed above?

Any other genetic history?

Do you, the patient, live with someone with TB or exposed to TB?

History of genital herpes?

History or current STD (Chlamydia, gonorrhea, HPV, Syphilis, HIV, Hepatitis)

History or current illicit or recreational drug use (non-prescription medication, marijuana, THC, methamphetamines, cocaine, ecstasy)

Any other infection history, like MRSA

Interested in the Maternal and Infant Program at RCHD? This includes incentives and education.

Interested in being enrolled in the Free Formula program?

Do you live in a home with cats?

Free Text

Previous Pregnancy Information

How many total times (including this pregnancy) have you been pregnant?

Pregnancy #1

Outcome or type of delivery

Number of weeks gestation at outcome or delivery

Birth weight

Sex of baby

Did you experience any preterm labor or any other conditions during pregnancy?

Pregnancy #2

Outcome or type of delivery

Number of weeks gestation at outcome or delivery

Birth weight

Sex of baby

Did you experience any preterm labor or any other conditions during pregnancy?

Pregnancy #3

Outcome or type of delivery

Number of weeks gestation at outcome or delivery

Birth weight

Sex of baby

Did you experience any preterm labor or any other conditions during pregnancy?

Pregnancy #4

Outcome or type of delivery

Number of weeks gestation at outcome or delivery

Birth weight

Sex of baby

Did you experience any preterm labor or any other conditions during pregnancy?

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EMAIL: admin@twhg.net

New OB Questionnaire

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CONTACT INFORMATION

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