Patient Medical History Page 3
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5Allergies: (Food, Drugs, Environmental) None Latex Iodine
Allergy
Interaction
Allergy
Interaction
Family Medical History: Please indicate below significant medical problems of family members. Indicate which
family member by checking the appropriate column and the AGE OF ONSET: No Family History Adopted
Blood Clots/DVT
Breast Cancer
Cervical Cancer
Colon Cancer
Diabetes
Ovarian Cancer
Hypertension
Stroke
Uterine Cancer
Other Cancers
not mentioned
Other disease’s
not mentioned
Genetic Screening: None
Includes patient, baby’s father, or anyone in either family
Indicate Yes or No
Yes No
Yes No
Tay-Sachs
Sickle Cell Disease or Trait
Neural Tube Defect
Maternal Metabolic Disorder
Other inherited Genetic or chromosomal Disorder
Mental Retardation/Autism
Thalassemia
Medication/Street Drugs/Alcohol
Hemophilia
Muscular Dystrophy
Cystic Fibrosis
Huntington Chorea
Down Syndrome
Congenital Heart defect
Patient or father of the baby had/has a child with birth
Recurrent pregnancy loss or a still
defects not listed
birth
3.
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