Obstetrical Patient Medical Information Check-In Sheet

Gynecological Health History

1. When was your last Pap smear? ______________ Have you ever had an abnormal Pap smear? ______________

If yes, when and where were you last treated? _____________________________________________________________________________________

What was the diagnosis? _____________________________________________

2. Have you ever had gonorrhea, chlamydia or pelvic inflammatory disease? ______

If yes, when and where were you treated? _______________________________________________________________________________________

3. Have you ever had herpes? ___________________________________________________________________________________________________

4. Have you ever used an IUD (intrauterine device) for contraception? ________ If yes, please indicate when _____________________________________

Did you have any problem with the IUD? ______ Please describe: ____________________________________________________________________

5. Do you have a history of infertility? ________ If yes, please describe when and treatment received ___________________________________________

____________________________________________________________________________________________________________________________

6. Please list any other concerns you have related to your past health history: ______________________________________________________________

____________________________________________________________________________________________________________________________

7. Do you have any religious objections to any form of medical treatment that you would like to make us aware of (i.e. refusal of blood transfusion.):

____________________________________________________________________________________________________________________________

Family History and Genetic History

Total Pregnancies __________

Deliveries __________

Miscarriages __________

Abortions _________

Vaginal or C-Section or Miscarriage or Abortion

Date of delivery

Number of

Male or Female

Baby’s Weight at Delivery

Weeks

1. Have either you or the baby’s father had a child born with a birth defect?

Yes______ No______

If yes, please describe: _________________________________________

2. Did either you or the baby’s father have a birth defect yourselves?

Yes______ No ______

If yes, please describe: _________________________________________

3. Please describe any abnormalities that have occurred in children in your family or the baby’s father’s family (for example, mental retardation, birth defects,

deformities, or inherited diseases like hemophilia, muscular dystrophy, or cystic fibrosis).

____________________________________________________________________________________________________________________________

How is the affected child/person related to you?______________________________________________________________________________________

4. Do either you or the baby’s father have a history of pregnancy losses (miscarriages or stillborn)?

Yes______ No______

If yes, have either of you had genetic counseling?

Yes______ No______

If yes, have either of you had chromosomal studies?

Yes______ No______

Where and results: _______________________________________________________________

5. Some genetic problems occur more in couples with certain racial or ancestral backgrounds. Please check if either you or the baby’s father is of one of these

backgrounds:

Jewish ancestry

_____No _____Yes If yes, have you had Tay-Sachs screening tests?

Yes______ No______

Date:______________ Result: ________________________

Black?

_____No _____Yes If yes, have you had Sickle Cell screening?

Yes______ No______

Date:______________ Result:________________________

6. Please mark if anyone in your family or the baby’s father’s family has:

Diabetes

_____No _____Yes If yes, how is that person related to you?____________________________________________________