Author: RZ

The Christ Hospital Family Medical Associates
OB Supplemental Information
Name / Birthdate _______________________
Please complete the following information to help us consider any risk factors you may have for you and your baby. If you need help completing the form, please leave this form blank and let the Medical Assistant who shows you to your room know that you need assistance. Thank you !
Genetic Information : Please complete this information for you, the father of the baby, & families
Autism Yes / No Mental Retardation Yes / No
Heart Defect at birth Yes / No Spina Bifida/Neural Tube Yes / No
Muscular Dystrophy Yes / No Cystic Fibrosis Yes / No
> 2 pregnancy losses Yes / No Canavan Disease Yes / No
Stillbirth _____ months Yes / No Down’s Syndrome Yes / No
Fragile X Syndrome Yes / No Tay-Sachs Disease Yes / No
Sickle Cell Disease or Trait Y / No Thalassemia Yes / No
Prior Genetic Counseling Yes / No Movement Problems Yes / No
Prior Cystic Fibrosis test Yes / No If yes, what year? _____________
Metabolic Disease (Diabetes,Thyroid, etc.) ________________ Yes / No
Other birth defects of genetic problems : ________________________________
___________________________________________________________
Infection History : Please complete this section for YOU and YOUR PARTNER (s)
Viral hepatitis Yes / No
Herpes Virus Yes / No
Tuberculosis Yes / No
MRSA (staph) Yes / No
Chickenpox Yes / No
Rash during preg. Yes / No
Sexually Transmitted Disease * Yes / No If yes : ___________________________
Other infections Yes / No If yes: ____________________________
* Herpes, HPV / Warts, Gonorrhea, Trichomonas, Chlamydia, HIV, Syphilis
PLEASE TURN OVER

OB Supplemental Information (continued—page 2)
Name / Birthdate _______________________
Previous Obstetrical / Pregnancy History : Please let us know if YOU have had the following.
* Please provide details on the lines next to any “Yes” answers. ( example—year, which pregnancy)
C-section delivery Yes / No ____________________________________
Fetal demise Yes / No ____________________________________
HELLP Syndrome Yes / No ____________________________________
Placental problems Yes / No ____________________________________
Preterm Labor Yes / No ____________________________________
Preterm Birth > 20 weeks Yes / No ____________________________________
ABO/Rh Incompatibility Yes / No ____________________________________
Shoulder “dystocia” Yes / No ____________________________________
Hemorrhage after delivery Yes / No ____________________________________
Postpartum Depression Yes / No ____________________________________
Newborn death Yes / No ____________________________________
Baby with Group B Strep DISEASE Yes / No ____________________________________
Previous Obstetrical and Gynecology Surgeries : Have YOU had any of the following?
Breast biopsy or Surgery Yes / No ____________________________________
LEEP / cutting the cervix Yes / No ____________________________________
Cervical cerclage Yes / No ____________________________________
D&C dilatation/curettage of uterus Yes / No ____________________________________
Laparoscopy / Laparotomy Yes / No ____________________________________
Tubal ligation/tied or reversal Yes / No ____________________________________
Uterine Fibroid / Polyp removal Yes / No ____________________________________
Is there anything else that you would like us to know or that is concerning to you ?
____________________________________________________________________
Thank you for taking time to share this information with us. Feel free to update this information during the pregnancy if anything changes. Please share any questions with your doctor or midwife.