New Patient Packet - North Texas Perinatal Associates Page 3
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4North Texas Perinatal Associates
HEALTH INFORMATION FORM
“Committed to turning high-risk pregnancies into low-risk deliveries.”
Today’ s Date: ___________________________
Last Name:
First Name:
M.I.:
Date of Birth:
Age:
Baby’s Father’s Age:
Referring Physician:
Estimated Due Date:
First Day of Last Menstrual Cycle (Full Date):
Reason For Consultation:
Pregnancy Complications:
Are you allergic to any medication? q YES q No If YES, indicate:
Height/Altura: ______ (inches) Weight/Peso:______ (lbs.)
ALL Past Pregnancies, miscarriages or abortions.
Year/Año
Gender
Type
Complications, Birth Defects and/or Reason for C-Section
Weeks at Delivery
BirthWeight
1)
M / F
Vaginal/C-Section
2)
M / F
Vaginal/C-Section
3)
M / F
Vaginal/C-Section
4)
M / F
Vaginal/C-Section
5)
M / F
Vaginal/C-Section
Medical History, Do you or have you had any of the following
YES
NO
YES
NO
YES
NO
Abnormal Uterus/Fibroids
High Blood Pressure
Kidney Disease
Incompetent Cervix
Asthma
Hepatitis/Liver Disease
Prior Cervical/Uterine Surgery
Lupus/Rheumatoid Arthritis
Inflammatory Bowel Disease
IVF or Donor Eggs
Diabetes/Gestational Diabetes
Seizure Disorder/Epilepsy
Genetic Disorders
Cancer
Thyroid Disease
Anemia/Blood Transfusions
Blood Clots/Pulmonary Embolism
Anxiety/Bipolar/Depression
Heart Disease/Murmur
Thrombophilia
HIV
Other/Otro:
Operations - Surgeries
Date
Procedure
Date
Procedure
Genetic History/ Antecedentes
Ethnicity: African American / Asian / Cajun / Caucasian / French Canadian / Hispanic / Jewish / Mediterranean / Other:
Baby’s Father’s Ethnicity: African American / Asian / Cajun / Caucasian / French Canadian / Hispanic / Jewish / Mediterranean / Other
Please answer the following questions:
NO
YES
Have you had any medication exposure during the pregnancy?
Have you had any x-ray exposure during the pregnancy?
Have you had a rash or fever during the pregnancy?
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