New Obstetrical Patient Information Form Page 9

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J
A. G
, MD
UDITH
URDIAN
M
S
, MD
ICHELLE
PECTOR
P
E. S
, PA-C
ATRICIA
HEVOCK
M
T
-H
, CNM
ELANIE
HORNTON
UYCKE
Yes
No
Do you have recurrent urinary tract infections, kidney ailments, or high
blood pressure?
Have you ever had a prior premature or immature delivery?
Have you ever been told that you have a “weak” or incompetent cervix?
Do you have any cardiac problems, including Rheumatic Heart Disease,
Congestive Heart Failure, or Mitral Valve Prolapse?
Have you ever been advised to have a prophylactic antibiotic before
dental work, surgery, or childbirth?
Are you frequently exposure to blood in a medical or dental setting or
work in a renal dialysis unit?
Have you ever been rejected as a blood donor?
Do you have acute or chronic liver disease, live in a household with
persons infected with Hepatitis B, or have been exposed to it?
Do you have a medical illness which requires blood transfusions?
Have you ever had a genital lesion which you thought might be Herpes
or genital warts?
Have you ever been told that you have a bleeding tendency, low
platelets (Idiopathic Thrombocytopenic Purpura), or any trouble with
your clotting system?
Have you ever had a severe intestinal illness, such as Ulcerative Colitis
or Crohn’s Disease?
Are you a Jehovah’s Witness? Would you refuse blood or blood
products to preserve your life or health or that of your baby?
Do you object to being screened for HIV and STDs?
Healthcare for w om en, by w om en…
9711 Medical Center Drive, Suite 109, Rockville, MD 20850
|
301.762.5501
|
Fax 301.309.8727
9

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