Plymouth Family Physicians - Pregnancy Questionaire

QUESTIONAIRE FOR YOUR PREGNANCY

The following is a long form requesting details of your health history and your pregnancy. This will assist us in providing thorough care and in obtaining needed services for your pregnancy. Even if this is not your first pregnancy or your first with Plymouth Family Physicians, we would like you to complete this to make sure that you are getting the best care possible for this current pregnancy.

Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

GENERAL INFORMATION

Patient's name (required)

E-mail Address

PAST MEDICAL HISTORY

1. Did you have any health problems at birth or in childhood?

2. Please list any hospitalizations and surgeries, and if possible, the approximate dates:

3. Have you had a complete set of childhood immunizations?
Yes No

4. Please list the date of your last tetanus shot.

5. Are you aware of any prior medical problems including (check all that apply):

Diabetes	Kidney Disease
Urinary Tract Infections	Significant Head Injury
High Blood Pressure	Epilepsy
Heart Disease	Heart Murmur
Blood Clotting Difficulty	Depression
Rheumatic Fever	Anemia
Jaundice	Hepatitis
Thyroid Abnormalities	Ulcer Disease
Heartburn	Varicose Veins
Blood Transfusions	Blood Clots
Other (please explain)

6. Have you ever been advised to have antibiotics before dental appointments or surgery? Yes No

7. Have you had any rashes or viral illnesses since your last menstrual period? Yes No

8. Do you have any history of exposure to tuberculosis or have you had a positive TB skin test? Yes No

9. Have you ever had any sexually transmitted infections ("STD")?
Yes No

10. Do you eat wild game or raw meat? Yes No

11. Have you or your partners had a history of genital herpes?
Yes No

12. You will be advised to have testing for the AIDS virus during your pregnancy according to the universal precautions recommended by the Center for Disease Control. As with all HIV testing, this will require your signature on a consent form. We do confidential testing here, which means that the results are not linked with your chart or with your name, and are coded so that only you and your health care providers in this office will be aware of any result.

13. Do you have cats living in your home? Yes No
If yes, have you arranged for someone else to handle all cat litter?
Yes No

MARITAL STATUS, PREGNANCY PLANNING, EDUCATION

1 . Was your pregnancy planned? Yes No

2. Are you married? Yes No
If yes, for how many years?

3. What is your hometown?

4. What was the last grade you completed in school?

5. What is your occupation?

Where do you work?

What hours?

6. The following questions relate to the baby's father:
	Name:
	Hometown:
	Age:
	Occupation:
	Employer:
	Work hours:
	Last grade completed:

SUPPORT SYSTEM

1. Do you have a religious preference and are you active in a church now?
Yes No Please list

2. Describe the level of support and involvement of the baby's father.

3. Who will be with you for the birthing?

4. Do you anticipate having an additional support person or ("doula") with you? Yes No

5. Would you like referral to available doulas in this area?
Yes No

6. Who will be available to help you when you are home with this new infant?

7. Do you have friends or family available for emergency transport in case your normal transportation is not available? Yes No

8. Is there a history of abuse in either your family or your spouse's family?
Yes No

LIVING ARRANGEMENTS

1. Who do you live with at this time?

2. Please describe your current housing arrangements and please let us know if you feel these arrangements will remain secure for the duration of the pregnancy and after your child is born.

3. Please list telephone numbers where you may be reached.
Your Home Phone:

Your Work Phone:

Spouse's/Significant Other's Home Phone:

Spouse's/Significant Other's Work Phone:

4. Is there another number that we can contact you in the case of an emergency?

5. How will you get to your regularly scheduled appointments and do you have a preference as to the time or day of the week that those appointments would be scheduled?

ECONOMIC / FINANCIAL CONCERNS

1. What financial concerns do you have?

2. What insurance do you carry for the pregnancy?

HABITS AND ENVIRONMENTAL CONCERNS

1. Do you smoke? Yes No
If so, how many cigarettes per day?

2. Have you had any alcohol since your last menstrual period?
Yes No

3. Have you used any street drugs since your last menstrual period?
Yes No

4. Do you use a hot tub or a sauna? Yes No

5. Are you exposed to any environmental work hazards on your job?
Yes No

6. Have you had any x rays since your last menstrual period?
Yes No

7. Are you exposed to any chemicals at home or at work?
Yes No

8. Any concerns about sexuality or sexual function?
Yes No

NUTRITION

Please list your pre-pregnant weight : lbs.

1. Have you had any weight loss or weight gain in the last six months?
Yes No If yes, please explain:

2. Do you have any food allergies? Yes No
If yes, please explain:

3. Do you have any foods that you dislike and avoid?
Yes No If yes, please explain:

4. How many meals per day do you eat?

5. Do you eat breakfast every day? Yes No

6. How much do you drink each day of each of the following:

Soda		Coffee		Water
Tea		Milk		Juice

7. How many half cup servings of fruit do you eat per day?

8. How many half cup servings of vegetables do you eat per day?

9. Were you taking any vitamins before the pregnancy? Yes No

10. Are you taking vitamins now? Yes No Please explain:

11. Are you on any natural medications, herbs or supplements?
Yes No Please explain:

12. How much weight have you gained in previous pregnancies?
lbs.

PLEASE CHECK ANY PROBLEMS LISTED BELOW THAT YOU HAVE HAD IN THE LAST YEAR:

Fever, chills, night sweats

Headaches, head injuries,concussion

Eye problems (wear contacts or glasses?)

Ear problems, hearing loss, ringing, pain

Thyroid problems or x ray treatment to neck or chest

Breast masses, breast discharge, breast pain

Breathing problems, shortness of breath, asthma, bronchitis, pneumonia, emphysema

High blood pressure, rheumatic fever, chest pain, palpitations or skipped beats, heart murmur

Heartburn, ulcers, gallstones, constipation, diarrhea, bloody or black bowel movements, abdominal pain

Kidney or bladder infection, leaking urine, pain with urination, kidney stones

Muscle pain, joint pain or swelling, broken bones, dislocations, muscle weakness

Seizures, loss of coordination, tremors, speech problems, memory loss, numbness, tingling

Skin changes, mole change, skin infections, hair loss, psoriasis

Bleeding from any site, clotting problems, bruising easily, transfusion
If yes to transfusions, what year?

Depression, poor sleeping, appetite problems, panic attacks, suicidal thoughts or attempts

Include any additional information you feel is important:

GYNECOLOGIC AND OBSTETRIC HISTORY

1. How old were you when you had your first period?

2. How often do you get your period?

3. How many days does it last?

4. Please list the first day of your last normal period.

When did you have a positive pregnancy test?

5. Have you had any spotting or bleeding since your last menstrual period?
Yes No

6. Have you had any surgery on your uterus, ovaries or cervix?
Yes No

7. Have you had any abnormal pap smears? Yes No

8. When was your last pap smear?

9. Have you had any testing or treatment done for infertility?
Yes No

10. Did your mother take any medication during her pregnancy with you to prevent miscarriage (for example, DES)? Yes No

11. What types of birth control have you used in the past?

PAST OBSTETRICAL HISTORY

How many pregnancies have you had? (If none, you will be taken to the next section of the form after making your selection here.)

Please list the following information for each pregnancy including any pregnancies not carried to term:

First pregnancy:

Date

Sex

Name

Birth Weight lbs. oz.

How many weeks along were you when you delivered?

Length of labor (in hours)

Type of delivery

Complications Yes No If yes, please explain:

Problems with baby? Yes No If yes, please explain:

Did you breastfeed? Yes No If yes, how many months did you breastfeed?

Hospital

Other comments:

If you have not had any additional pregnancy, click here to be taken to the next applicable section.

Second pregnancy:

Date

Sex

Name

Birth Weight lbs. oz.

How many weeks along were you when you delivered?

Length of labor (in hours)

Type of delivery

Complications Yes No If yes, please explain:

Problems with baby? Yes No If yes, please explain:

Did you breastfeed? Yes No If yes, how many months did you breastfeed?

Hospital

Other comments:

If you have not had any additional pregnancy, click here to be taken to the next applicable section.

Third pregnancy:

Date

Sex

Name

Birth Weight lbs. oz.

How many weeks along were you when you delivered?

Length of labor (in hours)

Type of delivery

Complications Yes No If yes, please explain:

Problems with baby? Yes No If yes, please explain:

Did you breastfeed? Yes No If yes, how many months did you breastfeed?

Hospital

Other comments:

If you have not had any additional pregnancy, click here to be taken to the next applicable section.

Fourth pregnancy:

Date

Sex

Name

Birth Weight lbs. oz.

How many weeks along were you when you delivered?

Length of labor (in hours)

Type of delivery

Complications Yes No If yes, please explain:

Problems with baby? Yes No If yes, please explain:

Did you breastfeed? Yes No If yes, how many months did you breastfeed?