Obstetric New Patient Questionnaire
Patient Name: _______________________________________ Age: ___________________
Partner/Father’s Name: ________________________________ Age: ___________________
How did you hear about us? ____________________________________________________________
Occupation: ________________________________Education: ________________________________
Pharmacy, Phone Number: _____________________________________________________________
Primary MD, Phone Number: ____________________________________________________________
Stress Level: low/med/high
Office use only: EDD: ________ GA: ______ PPWt: ______ Wt: ______ Ht: ______ BP: ________
Today’s Visit:
Current Complaints (i.e. Nausea/Vomiting/Breast Tenderness/Bleeding):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
Current Medications and Supplements:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Allergies to Medication/Food/Latex: ________________________________________________________________
_____________________________________________________________________________________________
Past Surgeries/Hospitalizations: ___________________________________________________________________
_____________________________________________________________________________________________
Diet (i.e. Regular, Vegetarian, Gluten Free, etc.): _____________________________________________________
Exercise (how often): ___________________________________________________________________________
Gynecologic/Obstetrical History:
On what date did your last menstrual period start?
Are your menses monthly and regular?
How many days from the start of one menses to the next?
Menses Flow (light, moderate, heavy)?
Duration of Flow (days)?
At what age did you first get your menses?
Current Birth Control Method?
What age were you when you had your first child (if applicable)?
Abnormal Pap Smear History? If so, explain:
How many pregnancies have you had?
How many pregnancies have you delivered at full term (>37 weeks)?
How many pregnancies have you delivered prematurely (<37 weeks)?
How many abortions have you had?
How many miscarriages have you had?
Have you ever had an ectopic (tubal) pregnancy?
Have you ever had twins or triplets?
How many children do you currently have living?
On what date did you have your first positive pregnancy test?
Date of Delivery: MM/DD/YY
Weeks Pregnant at time of
delivery:
Number of hours you labored:
Birth Weight of baby:
Sex of baby:
Mode of delivery
(vaginal/forceps/vaccum/csection):
Type of anesthesia used
(none/IV meds/epidural):
Place of delivery (home/birth
center/hospital):
Preterm Labor (yes or no)
Name of baby:
Additional Comments:
Please circle all problems below that you have ever had and write any details about this problem. Please also
indicate any family members who may have these problems. Example: Children, Parents, Siblings, Grandparents,
Aunts, Uncles, 1st cousins. Please indicate if maternal or paternal.
Alcohol: _______________________________________________________________________
Anemia: _______________________________________________________________________
Anesthetic Complications: ________________________________________________________
Anxiety: ______________________________________________________________________
Arthritis: _______________________________________________________________________
Asthma: _______________________________________________________________________
Autoimmune Disorder (Lupus/Rheumatoid): _________________________________________
Breast Problems: _______________________________________________________________
Caffiene:______________________________________________________________________
Cancer: _______________________________________________________________________
D (Rh) Sensitivity: _______________________________________________________________
Depression/Post-Partum Depression: _______________________________________________
Diabetes: ______________________________________________________________________
Endometriosis: ____________________________________________________________________
GI Problems: _____________________________________________________________________
Gyn Surgery: ___________________________________________________________________
Headaches or Migraines: __________________________________________________________
Heart Disease: _________________________________________________________________
Hepatitis/Liver Disease: __________________________________________________________
History of abnormal Pap smear: ___________________________________________________
History of Blood Transfusions: _____________________________________________________
Hypertension (High Blood Pressure): _________________________________________________
Illicit/Recreational Drug Use: ______________________________________________________
Infertility: _____________________________________________________________________
Kidney Disease/UTI: ____________________________________________________________
Lung Disease: ____________________________________________________________________
Neurologic/Epilepsy: ____________________________________________________________
Operations/Hospitalizations: ______________________________________________________
Ovarian Cancer: ________________________________________________________________
Psychiatric Illness: _________________________________________________________________
Pulmonary (TB/Asthma): _________________________________________________________
Seasonal Allergies: ______________________________________________________________
Thyroid Disorders: ______________________________________________________________
Tobacco use (smoking): __________________________________________________________
Trauma/Violence: _______________________________________________________________
Uterine anomaly/DES Exposure: ___________________________________________________
Varicella immune? (chicken pox): __________________________________________________
Varicose Veins/Phlebitis: _________________________________________________________
When was your last Pap smear: ___________________________________________________
Would you accept blood products: _________________________________________________
Family Genetic History:
Patients age at time of delivery: ___________________________________________________
Any history of the following: ______________________________________________________
Thalassemia or are you of Italian, Greek, Mediterranean or Asian decent: __________________
Neural Tube Defects: ____________________________________________________________
Congenital Heart Defects: ________________________________________________________
Down syndrome: _______________________________________________________________
Tay-Sachs (eg, Jewish, Cajun, French-Canadian): _______________________________________
Canavan disease: _______________________________________________________________
Sickle cell disease or trait: _________________________________________________________
Hemophilia or other blood disorder: ________________________________________________
Muscular dystrophy: _____________________________________________________________
Huntington’s Chorea: _____________________________________________________________
Cystic Fibrosis: _________________________________________________________________
Mental Retardation/Autism: ______________________________________________________
If yes, was person tested for fragile X: _______________________________________________
Other inherited genetic or chromosomal disorder: _____________________________________
Recurrent pregnancy loss or stillbirth: _______________________________________________
Medication/Illicit/Recreational Drugs or alcohol since last menstrual period: ________________
If yes, what agent and strength/dosage: _____________________________________________
Any other genetic history: _________________________________________________________
Infection History:
Live with someone with or been exposed to TB: _______________________________________
Patient or partner with genital or oral herpes (cold sores/fever blisters): ____________________
Rash or viral illness since last menstrual period: _______________________________________
History of STD: _________________________________________________________________
Do you have any cats: ____________________________________________________________
History of MRSA: ________________________________________________________________
Other infection history: ______________________________________________________________