Reproductive Health Questions printable pdf download

Name: ___________________

Date: ___________________

Reproductive Health Questions

Your Medical History. Please list any medical conditions that you have, such as diabetes, high

blood pressure, seizures, thyroid disease, depression, anemia, etc.

__________________________________________________________________

Your Medications. Please list any prescription or over-the-counter medications, vitamins,

herbs, or supplements that you take on a regular basis.

__________________________________________________________________

Your Pregnancy History.

How many pregnancies have you had?

____ □ None (if ‘none’, skip to ‘Your Family Medical

History section).

How many babies have you delivered early (before 37 weeks)?

____

□ None

How many babies have you delivered weighing less than 5 lbs 8 oz?

____

□ None

How many miscarriages have you had?

____

□ None

How many abortions have you had?

____

□ None

During any of your pregnancies, did you have any problems like:

High blood pressure

□ Yes

□ No

Diabetes

□ Yes

□ No

Vaginal bleeding

□ Yes

□ No

Premature labor

□ Yes

□ No

Your Family Medical History. Please put an ‘x’ in the box for any conditions that run in your

family.

□ Birth defects (like heart problems, open spine, cleft palate, or other problems)

□ Miscarriages, stillbirths, or children who die soon after birth

□ Hearing loss or deafness

□ Vision loss or blindness

□ Mental retardation, learning disabilities, or Fragile X syndrome

□ Cystic fibrosis

□ Hemophilia

□ Sickle cell trait or disease

□ Muscular dystrophy

□ Phenylketonuria

□ Other __________________________________________________________

Georgia “Every Woman, Every Time” Preconception Care Toolkit

Reproductive Health Questions

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