New OB Worksheet

Alison L. Buck, M.D. Steven E. Calvin, M.D.
Sheila Goodman, M.D. Meredith Kasbohm, M.D.
Myriah Hanno, M.D. Rebekah Ormsby, M.D.
Patricia M. Pettit, M.D. Jill H. Rusterholz, M.D.
Teresa Pattison, WHCNP. Debra Stealey, CNM.

Demographic Data



Marital Status

Single

Married

Divorced

Widowed

Partnered

1. Menstrual History

days

days

Yes
No

Yes
No

Yes

No

Yes

No

Yes
No

Total # pregnancies Full term Preterm Miscarriage/Abortion Living

2. Past Pregnancies Including Miscarriages and Abortions

Date mm/dd/yyyy Gest. Weeks Length of Labor Birth Weight Sex M/F Type Delivery Anes. Place of Delivery Preterm Labor Yes/No Gestational Diabetes Yes/No Comments
Complications

3. Past Medical History

1. Diabetes

2. Hypertension (High Blood Pressure)

3. Heart Disease

4. Autoimmune Disorder(Lupus/Antiphospholipid Synd.)

5. Kidney Disease / UTI

6. Neurologic (Epilepsy)

7. Psychiatric (Anxiety/Depression)

8. Hepatitis / Liver Disease

9. Varicosities / Phlebitis

10. Thyroid Dysfunction

11. Trauma / Violence

12. History of Blood Transfusion

13. Pulmonary (TB, asthma)

14. Allergies (Drugs)

15. Gyn Surgery

16. Operations/Hospitalizations (Year and Reason—list below)

17. Anesthetic Complications

18. History of abnormal Pap

19. Uterine anomaly

20. DES

21. Infertility

22. Relevant Family History

23. Other

24. None of the above

4. Infection History/Workplace Environment Risk

1. HIV/Risk Factors

2. Used IV Drugs

3. Immunized for Hepatitis B

4. Live with Someone with TB or Exposed to TB

5. Patient or Partner has history of Genital Herpes

6. Rash or Viral Illness since last Menstrual Period

7. History of STD, GC, Chlamydia, HPV, Syphilis

8. Have you had chicken pox or been immunized

9. DT immunization up­to­date?

10. Exposed to cat litter

11. Exposed to lead or chemicals

12. Exposed to radiation

13. Exposed to infections (hospital, labwork, day care, etc.)

14. Is there a high level of stress at work/home

15. Stands for prolonged periods of time

16. Sits for prolonged periods of time

17. Lifts heavy objects repeatedly

18. Other

5. Social History

Attitude towards pregnancy:

Planned

Unplanned

Plan to parent/keep

Adoption

Drug use: (Past/Current):

Tobacco

Yes

No

Alcohol

Yes

No

Caffeine

Yes

No

Yes
No

yes

6. Genetic Screening History

Have you or any members of your family been born with or affected by any known genetic problem, birth defects, or major medical problems?

1. Patient’s Age ≥ 35 yrs.

2. Father of baby ≥ 50 yrs.

3. Italian, Greek Mediterranean or Asian background (thalassemia)

4. Jewish, Cajun, Fr. Canadian background (Tay Sachs)

5. African or Latin American background (sickle cell)

6. Down syndrome or other chromosomal problem

7. Hemophilia or other bleeding disorder?

8. Muscular dystrophy

9. Adopted-family history unknown

10. Cystic Fibrosis or any other metabolic disorder

11. Huntington’s Chorea

12. Mental retardation or autism

13. Maternal medical problems (diabetes, lupus, epilepsy, PKU, etc.)

14. Other inherited genetic or chromosomal disorder

15. Child with birth defects not listed above

16. ≥ 3 first trimester spontaneous abortions or a stillbirth?

17. Other

18. None of the above