Patient Information Template Page 2

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G
OB/GYN A
, P.C.
WINNETT
SSOCIATES
♦
♦
♦
1700 Tree Lane Road
Suite 290
Snellville, GA 30078
(770) 972-0330
Prenatal Record
Date:
Name:
Last
First
Middle
Maiden
Date of Birth
S M W D SEP
Age
Religion
Race
Country of Birth
Marital Status
Occupation
(Please circle one)
Address
Phone Number
Education
Name of Father of Child
His Age
Ht.
Wt.
Father of Child’s Occupation
(
)
(
)
(
)
Your Business Phone
Father of Child’s Business Phone
Your Cell Phone
FAMILY HISTORY: List relationship of family member with any of the following
Tuberculosis
Psychological
Cancer:
Colon
Hypertension
Epilepsy
Breast
Heart Disease
Allergies
Vagina/Vulva
Diabetes
Multiple Births
Cervix
Neurological
Birth Defects
Uterus
Ovaries
Significant Diseases:
Other:
MENSTRUAL HISTORY:
Amount (circle one)
Interval
Days
Duration
Days
Onset at
Years
Lt.
Mod.
Hvy.
First day of last menstrual period?
Type of last of birth control
When last used?
Was it normal?
Yes No
0 NEG.
0 NEG.
YOUR PERSONAL PRIOR
HISTORY SINCE YOUR LAST
REMARKS
REMARKS
√ POS.
√ POS
MEDICAL HISTORY
MENSTRUAL PERIOD
Heart Disease/Murmurs
Douche
High Blood Pressure
Nausea/Vomiting
Asthma, TB
Indigestion/Constipation
Stomach or Bowel Disease/ Hepatitis
Headache
Bleeding (Specify)
Bladder or Kidney Disease/Infections, Stones
Gonorrhea/Chlamydia/Syphilis
Vaginal Discharge
Genital Warts or Herpes
Swelling
Gyn. Disorder/Gyn. Surgery
Abdominal Pain
DES Exposure/Abnormal Paps
Urinary Problems
Nervous and Mental Problems
Viral Infection
Diabetes/Thyroid Problems
Other Illness/Fever
Phlebitis, Varicosities
X-rays
Epilepsy, Neurological Disorder
Accidents
Drug Allergies
Medications/including OTC
Drug Abuse/History of Use
Tobacco Use
Pt. Couns
Blood Disease/Transfusions
Drug Use
Pt. Couns
Cancer
Alcohol Use
Pt. Couns
Rh, ABO Sensitivity
HIV Exposure
Pt. Couns
Cats/Raw Meats (Toxo Risks)
Pt. Couns
Operations, Accidents, Hospitalization
Anesthetic Complications
Other
Have you had Chicken Pox?
Tattoos
PREVIOUS PREGNANCIES:
Full Term
Premature
Abortion/Miscarriage/Ectopic/Mole
Now Alive
Multiple Births
Length of
Length
Type of
Type of Pain
Weight
Complications
Comments/
No.
Year
Hospital
Pregnancy
of Labor
Delivery
Relief
of Child
Sex of Child
Mother
Child

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