OBSTETRICAL REGISTRATION

Please take the time to complete our obstetrical registration. This information will be made part of your permanent chart and will not be released to any other entity unless expressly requested by you.This form is secure and all information is encrypted to protect your personal information.

PERSONAL INFORMATION

Today's Date :

First Name:

Last Name:

Birth Date :

Age :

Last Grade :

Marital Status:

Father of Baby's Name:
(If applicable)

Father of Baby's Age:
(If applicable)

Father of Baby's Occupation:
(If applicable)

Race:

Religion:

Address:

City:

State:

Zip:

Cell Phone:

Home Phone:

Work Phone:

Patient's Occupation:

Insurance:

Hospital:

PREGNANCY HISTORY

Total # of Prenancies:

Full Term:

Premature Abortions.:

Abort.:

Ectopic:

Multiple:

Living:

First Pregnancy

Date:
(Mo/Yr)

Wks Gest:

Labor Hours:

Spont:

Ind.:

Type of Delivery

Alive/Dead:

Baby's Weight:

Sex:

Complications:

Second Pregnancy

Date:
(Mo/Yr)

Wks Gest:

Labor Hours:

Spont:

Ind.:

Type of Delivery

Alive/Dead:

Baby's Weight:

Sex:

Complications:

Third Pregnancy

Date:
(Mo/Yr)

Wks Gest:

Labor Hours:

Spont:

Ind.:

Type of Delivery

Alive/Dead:

Baby's Weight:

Sex:

Complications:

Fourth Pregnancy

Date:
(Mo/Yr)

Wks Gest:

Labor Hours:

Spont:

Ind.:

Type of Delivery

Alive/Dead:

Baby's Weight:

Sex:

Complications:

Fifth Pregnancy

Date:
(Mo/Yr)

Wks Gest:

Labor Hours:

Spont:

Ind.:

Type of Delivery

Alive/Dead:

Baby's Weight:

Sex:

Complications:

Sixth Pregnancy

Date:
(Mo/Yr)

Wks Gest:

Labor Hours:

Spont:

Ind.:

Type of Delivery

Alive/Dead:

Baby's Weight:

Sex:

Complications:

PAST HISTORY

Uterine Anomaly?	Yes No	Comments:

Infertility?	Yes No	Comments:

Abnormal PAP/CIN?	Yes No	Comments:

GYN Surgery?	Yes No	Comments:

Blood Transfusion?	Yes No	Comments:

Phlebitis?	Yes No	Comments:

Hypertension?	Yes No	Comments:

Diabetes?	Yes No	Comments:

Heart Disease?	Yes No	Comments:

Kidney Disease?	Yes No	Comments:

Thyroid Dysfunction?	Yes No	Comments:

Hepatitis/Liver Disease?	Yes No	Comments:

Nervous/Mental?	Yes No	Comments:

Major Accidents?	Yes No	Comments:

Street Drugs/Alcohol?	Yes No	Comments:

Tuberculosis?	Yes No	Comments:

Hospitalizations?	Yes No	Comments:

Surgery?	Yes No	Comments:

Genital Herpes?	Yes No	Comments:

Anesthetic Complications?	Yes No	Comments:

Allergies (Drugs)?	Yes No	Comments:

Asthma?	Yes No	Comments:

HIV Exposure?	Yes No	Comments:

OTHER?	Yes No	Comments:

FAMILY HISTORY (1st Degree Relatives Only)

Diabetes?	Yes No	Comments:

H.B.P?	Yes No	Comments:

Heart Disease?	Yes No	Comments:

Cancer?	Yes No	Comments:

Neuro?	Yes No	Comments:

Psych?	Yes No	Comments:

Blood Disorder?	Yes No	Comments:

Cong. Anomaly?	Yes No	Comments:

Twins?	Yes No	Comments:

OTHER?	Yes No	Comments:

PRESENT PREGNANCY HISTORY

Acute Illness Since Last Menstrual Period?	None	Comments:

Bleeding Since LMP?	None	Comments:

Planned Pregnancy?	Yes	Comments:

Medications Since LMP?	None	Comments:

Use of Tobacco Since LMP?	None	Comments:

Use of Alcohol or Street Drugs Since LMP?	None	Comments:

Date Discontinued Oral Contraceptives?	None	Comments:

PRENATAL SCREEN

1. Will you be 35 years or older when the baby is due?
Yes No

2. Have you, the baby's father, or anyone in either of your families ever had any of the following disorders?
-Down Syndrome (mongolism): Yes No
-Other Chromosomal abnormality: Yes No
-Neural tube defect, i.e., spina bifida (meningomyelocele or open spine), anencephaly: Yes No
-Hemophilia: Yes No
-Muscular Dystrophy: Yes No
-Cystic Fibrosis: Yes No

3. Do you or the baby's father have a birth defect?
Yes No

4. In this or any previous marriages, have you or the baby's father had a child, born dead or alive, with a birth defect not listed in question 2 above?
Yes No

5. Do you or the baby's father have any close relatives with mental retardation?
Yes No

6. Do you, the baby's father, or close relative in either families have a birth defect, any familial disorder, or a chromosomal abnormality not listed above?
Yes No

7. In this or any previous marriages, have you or the baby's father had a stillborn child or three or more first-trimester spontaneous pregnancy losses?
Yes No
Have either of you had a chromosomal study? Yes No

8. If you or the baby's father are of Jewish ancestry, have either of you been screened for Tay-Sachs disease?
Yes No

9. If you or the baby's father are black, have either of you been screened for sickle cell trait?
Yes No

10. If you or the baby's father are of Italian, Greek, or Mediterranean background, have either of you been tested for B-thalassemia?
Yes No

11. If you or the baby's father are of Philippine or Southeast Asian ancestry, have either of you been tested for A-thalassemia?
Yes No

12. Have you taken any prescribed medications, over-the-counter medications, recreational drugs, or alcohol since your last menstrual period? (include IV drugs)
Yes No

13. Have you ever had chicken pox?
Yes No

14. Have you or the baby's father ever had or been treated for a sexually transmitted disease, such as chlamydia, herpes, gonorrhea or syphillis?
Yes No

15. Have you or the baby's father had a positive test for AIDS or been exposed to AIDS?
Yes No

16. Are you and the baby's father related (besides marriage)?
Yes No

17. Have you or the baby's father ever been diagnosed as having Phenylketonuria (PKU)?
Yes No

18. Have you or the baby's father ever had Hepatitis?
Yes No

19. Have you ever been vaccinated for Hepatitis B?
Yes No

20. Do you work in the Health Care field?
Yes No

If you answered Yes to any of the questions, please describe here: