New Patient Packet - North Texas Perinatal Associates Page 4
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4Patient Name:
DOB:
North Texas Perinatal Associates
Referring Physician:
Misys MR #:
“Committed to turning high-risk pregnancies into low-risk deliveries.”
Do you, the baby’s father or any family member have any of the following
:
YES
NO
YES
NO
Mental Retardation
Down Syndrome
Fragile X
Tay Sachs
Mediterranean Anemia
Sickle Cell Disease
Cystic Fibrosis
Muscular Dystrophy
Neural Tube Defect
Heart Defect
Birth Defect
Other:
Have you had CF Carrier Testing?
Have you had any other genetic testing?
If so, what were the results?
If so, what test(s) and what were the results?
Social History – Do you or have you used any of the following during your pregnancy:
YES
NO
YES NO
Alcohol
Regular Exercise
Tobacco
Seat Belt Use
Drug Use
Other:
Review of Systems – Please check any of the following that CURRENTLY apply.
P
P
Genitourinary
Constitutional
Dysuria (Painful Urination):
Fatigue
Fever
Frequency
Weight Gain
Hematuria (Blood in Urine)
Weight Loss
Urgency
Muscle-Skeletal
Eyes
Pain
Double Vision
Spasm
Glasses / Contacts
Seeing Spots
Weakness
Vision Changes
Neurological
Numbness
Ears-Nose-Throat
Seizures
Headache(s)
Syncope (Fainting)
Sinusitis (Sinus Infection)
Difficulty Walking
Tinnitus (Ringing in Ears)
Hematologic
Ulcers
Adenopathy (Enlargement of Lymph Node)
Cardiovascular
Bleeding
Chest Pain
Bruising (Frequent)
Edema (Ex: Swelling of Legs)
Endocrine
Orthopnea (Shortness of Breath)
Diabetes Mellitus
Palpitations (Abnormal Heart Beat)
Hyperthyroid (Over Active Thyroid)
Respiratory
Hypothyroid (Under Active Thyroid)
Coughing
Psychiatric
Shortness of Breath
Anxiety
Wheezing
Bipolar
Gastrointestinal
Depression
Constipation
Skin
Diarrhea
Rash
Nausea
Striae (Stretch Marks)
Pain
Ulcer
Vomiting
Other:
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__________________________________
______________________________
Date of Signature
Patient Signature
Physician Signature
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