FRANCES TENG, M.D.
TONI MORRISSEY, M.D.
PAMELA PAYNE, N.P.
50 Alessandro Place, Suite 440
Pasadena CA 91105
626-440-9190
Welcome to our office. We look forward to working with you and your family during this
exciting time. If you have any questions before your first scheduled visit with us, please feel free
to call us. We have enclosed a booklet entitled “Important Information for Healthy Pregnancy”
to provide you with the information you need to take care of yourself throughout your
pregnancy. This information will help answer many of the questions you may have during this
early time of your pregnancy. Please bring this booklet with you to your first appointment, so
that we can help you with any questions you may have.
Before you come for your first visit, please complete the following form, which will give us
important information regarding your health history and contact information, and allow us to
provide the best care for your pregnancy. Please bring this form and your insurance card with
you to your first appointment.
Name of Patient (full name, as listed on your insurance card):
__________________________________________________________
Address:
______________________________________________
______________________________________________
Phone numbers:
Home ___________________________________
Work ___________________________________
Cell _____________________________________
Please circle the phone number you wish us to use first when we contact you with test results,
etc.
Age:
________
Birth date: _________________________
What type of work do you do? _________________________________
Name of your spouse/partner/baby’s father: ______________________________
What type of your work does your partner do? ____________________________
What is the best phone number to contact your partner if we need to?
___________________________________
What is the name and phone number of an emergency contact we can use in case we cannot
reach you or your partner? ________________________________________
Information about your current pregnancy
What is the date of the first day of your last menstrual period? __________________
Did this period seem normal, and come at the time you expected? ________________
What is the date of your positive pregnancy test? __________________________
Are you having (or have you had):
Nausea
Yes
No
Vomiting
Yes
No
Vaginal bleeding
Yes
No
Severe abdominal cramping
Yes
No
Other significant problems
Yes
No
Have you taken any prescription medicines, over the counter medicines, vitamins, herbal
supplements, alcohol, tobacco or recreational drugs since your last menstrual period?
Yes
No
If yes, please list them:
Have you been ill with a fever, rash or infection since your last menstrual period?
No
Yes
Information about your health
Do you currently have, or have had in the past, any of the following health issues (if yes, please
tell us when you had them):
Diabetes or Gestational Diabetes
High blood pressure or
No
No
Yes
Yes
high blood pressure in pregnancy (pre-eclampsia)
Heart disease
Kidney disease
Seizures, epilepsy or neurological diseases
Migraines
No
No
Yes
Yes
No
No
Yes
Yes
Blood clots in your deep veins (DVT)
No
Yes
or varicose veins
Thyroid problems
No
Yes
Asthma or chronic respiratory problems
No
Yes
Seasonal hay fever/allergies
No
Yes
Positive skin test for tuberculosis (TB)
No
Yes
Hepatitis or other liver disease
No
Yes
Breasts problems (such as pain, lumps or surgery)
No
Yes
Ever had surgery to your uterus or ovaries?
No
Yes
Ever had any other type of surgery?
No
Yes
Ever had a bad reaction to anesthesia (such as novocain
No
Yes
at the dentist)?
Ever received a blood transfusion?
No
Take medications for anxiety or depression?
Yes
No
Yes
If yes, what medications and when?
Had postpartum depression in a previous pregnancy?
No
Yes
Do you:
Smoke tobacco?
No
Yes
Drink alcohol?
No
Yes
Use recreational/street drugs?
No
Yes
Have you had chicken pox (varicella) in your lifetime?
No
Yes
Have you or the baby’s father ever had genital herpes? No
Any other sexually transmitted infection?
Yes
No
Take medicines or had procedures to help you become No
Yes
Yes
pregnant?
Are you allergic to any medicines?
No
Yes
No
Yes
If yes, what type of reaction did you have?
Have you ever been diagnosed with an allergy to
latex rubber?
When was your last pap test done? _________________________
Have you ever had an abnormal pap test?
History of any previous pregnancies
No
Yes
Have you had any previous:
Full-term pregnancies
No
Yes (how many?)
Premature deliveries
No
Yes (how many?)
Miscarriages
No
Yes (how many and when?)
Ectopic pregnancies
No
Yes (how many and when?)
Pregnancy loss in the second or third trimester? No
Yes
For each of your full term pregnancies or premature deliveries:
Birth
date
Full-term
Girl or
or
Boy/Baby’s
premature? name
Vaginal or Birth
C-section weight
Length of
labor
Hospital
or
Location
Please describe any significant complications for you or the baby in your previous pregnancies or
deliveries:
Patient’s Family Medical History
For your relatives related to you by blood, has anyone had:
Diabetes
High blood pressure
No
No
Yes
Who?____________
Yes
Who?____________
Heart attack
No
Yes
Who?____________
Stroke
No
Yes
Who?____________
History of Chromosomal or Inherited Diseases or Problems for Patient’s Family and the
Baby’s Father’s Family
Do you or the baby’s father have a family history of any of the following disorders? If your
answer is yes, please indicate how they are related to you and what the problem was, if you
know.
Blood disorder, such as thalassemia,
sickle cell disease or hemophilia
No
Yes
Who?
Neural tube defect (where brain or spinal cord
No
Yes
Who?
do not properly develop, such as spina bifida)
Heart problem at birth
No
Down’s syndrome
No
Mental retardation or autism
No
Yes
Who?
Yes
Who?
Yes
Who?
Genetic diseases:
Tay-Sachs
No
Yes
Who?
Muscular dystrophy
No
Yes
Who?
Cystic fibrosis
No
Yes
Who?
Huntington’s disease
No
Yes
Who?
Canavan disease
No
Yes
Who?
Are either you or the baby’s father of Ashkenazi Jewish heritage? No Yes
Please list any other inherited genetic or chromosome diseases in your families:
If the baby’s father has had children from a prior relationship, have they all been healthy?
Not applicable
Yes
No
Thank you for taking the time to complete this information. All of the information you
have given us will help us provide the best possible care to you and your baby during your
pregnancy. We will review the information with you at your first appointment, and help
you with any questions you may have regarding your health history.
(Rev. 1/08)