#NEW#OB#QUESTIONNAIRE - Northwest Women’s...
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1101 Madison St. Ste. 1150 Seattle, WA 98104 O: 206.386.3400 F: 206.386.3411 NEW OB QUESTIONNAIRE NAME DATE _______________ AGE PARTNER'S NAME ___________________________ BIRTHDATE PCP __________________________________ REFERRED BY OCCUPATION ______________________________ Last Menstrual Period VITAL SIGNS BP_________ EDD (Due Date) HT___________________ WT__________________ HAVE YOU HAD INFERTILITY TREATMENT? YES NO WHERE? CIRCLE ALL THAT APPLY: IUI IVF Donor Egg TWINS OBSTETRICAL HISTORY # Date Pregnancy Outcome Length (wks) Epidural? Gender Weight Name Hospital/DR Complications? (miscarriage, vag del C/S) 1 2 3 4 5 GYNECOLOGIC HISTORY for doctors use only Age at first period How many days do you bleed? Length of cycles (days between periods) Any vaginal itching or abnormal discharge? yes no Any history of recurrent (circle) Bacterial vaginosis Yeast HEALTH CARE MAINTENANCE for doctors use only Date of last pap smear Was it (please circle) Normal Abnormal If Abnormal, please list treatment/date Have you ever had: An abnormal pap? If yes, when _________ yes no Colposcopy/Cryotherapy/Biopsy/Laser/LEEP (circle) Human Papillomavirus (HPV) yes no
Transcript of #NEW#OB#QUESTIONNAIRE - Northwest Women’s...
1101 Madison St. Ste. 1150 Seattle, WA 98104 O: 206.386.3400 F: 206.386.3411
NEW OB QUESTIONNAIRE
NAME DATE _______________
AGE PARTNER'S NAME ___________________________
BIRTHDATE PCP __________________________________
REFERRED BY OCCUPATION ______________________________
Last Menstrual Period VITAL SIGNS BP_________
EDD (Due Date) HT___________________
WT__________________
HAVE YOU HAD INFERTILITY TREATMENT? YES NO
WHERE?
CIRCLE ALL THAT APPLY: IUI IVF Donor Egg TWINS
OBSTETRICAL HISTORY
# Date Pregnancy Outcome Length (wks) Epidural? Gender Weight Name Hospital/DR Complications? (miscarriage, vag del C/S)12345
GYNECOLOGIC HISTORYfor doctors use only
Age at first periodHow many days do you bleed?Length of cycles (days between periods)Any vaginal itching or abnormal discharge? yes noAny history of recurrent (circle) Bacterial vaginosis Yeast
HEALTH CARE MAINTENANCEfor doctors use only
Date of last pap smearWas it (please circle) Normal Abnormal If Abnormal, please list treatment/date Have you ever had:An abnormal pap? If yes, when _________ yes noColposcopy/Cryotherapy/Biopsy/Laser/LEEP (circle)Human Papillomavirus (HPV) yes no
1101 Madison St. Ste. 1150 Seattle, WA 98104 O: 206.386.3400 F: 206.386.3411
HEALTH CARE MAINTENANCE (continued)The HPV vaccine yes noA mammogram (date) yes noA colonoscopy (date) yes no
Have you ever had an STD ? yes no If yes, circle: Herpes Gonorrhea Chlamydia Syphilis HIV Any history of Hepatitis? yes no
SURGICAL HISTORYYear Surgical Procedure for doctors use only
MEDICAL HISTORYHave you ever had: yes no for doctors use onlyHigh blood pressureHigh cholesterolHeart diseaseEchocardiogramKidney problems (infections, stones)JaundiceUlcersBlood transfusionDeep Vein Thrombosis (DVT) Pulmonary Embolism (PE)AsthmaDiabetesThyroid diseaseHepatitisGallstonesColon problemsMigraine headaches OsteoporosisDepression/AnxietyCancerAutoimmune disorderEating disorderBreast LumpChicken PoxOther Medical History:
1101 Madison St. Ste. 1150 Seattle, WA 98104 O: 206.386.3400 F: 206.386.3411
FAMILY HISTORYHave any relatives had: (who?) yes noBreast cancerOvarian cancerColon cancerHeart attackStrokeHigh blood pressureDiabetesBirth defectsBlood clotsGenetic disordersTwinsDepression/Psychiatric disordersThyroid disorderOther conditions
SOCIAL HISTORY
Are you (circle): Single In a relationship Married Partnered Divorced OtherDo you for doctors use onlySmoke yes noDrink alcohol (prior to preg) yes noTake recreational drugs yes noWear your seatbelt yes noHave a history of abuse yes noFeel safe yes noExercise regularly yes noReligious preference
REVIEW OF SYSTEMSDo you currently have any of the following symptoms (please circle)Fatigue Urinary frequencyCramping Discomfort with urinationPelvic pain Skin rashHeadaches Indigestion or heartburnBreast lumps Joint painBreast tenderness or nipple discharge Heat/cold intoleranceChest pain Unwanted hair growthIrregular heart beat DepressionShortness of breath AnxietyUnusial vaginal discharge Easy bleeding or bruising (circle which)Nausea/Vomiting Seasonal allergiesDiarrhea Constipation
1101 Madison St. Ste. 1150 Seattle, WA 98104 O: 206.386.3400 F: 206.386.3411
MEDICATIONSPlease list current medications, doses, instructions (include vitamins and supplements)Medication Dose Frequency
MEDICATION ALLERGIES (and reaction)
Do you have a Latex allergy? Please circle: yes no
Anything else we should know to help us in your care?
