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SOUTHERN UTAH WOMEN’S HEALTH CENTER, PC HEALTH INFORMATION Name: ______________________________ Today’s date: _________________________ Allergies (Medication, Latex, food or Other) __________________________________________________ __________________________________________________ __________________________________________________ Past Medical History (Circle all that apply) Abnormal pap smear Asthma Bladder disorder (urinary stress incont) Breast lump/disorder Cancer Clotting disorder Depression/Anxiety Diabetes Type I Type II Epipilepsy/seizure disorder Herpes oral genital High blood pressure Thyroid disorder Hyper Hypo Infertility Liver disorder Osteoporosis Pelvic pain/cramping Pulmonary (lung)disorder Renal (kidney)disorder Sexually trans disease (STD) Past Surgical History Month/Year Abdominal surgery Appendectomy Breast (augmentation or other) Bladder C-section Laparoscopy __________ __________ __________ __________ __________ __________ Menstrual History First day of last menstrual period: _________________ Age when period started ________________ years old Number of days of flow _________________ days. (ie: 3, 5) Cycle interval (1st day to 1st day) _________ days. (ie: 28, 30, varies) Flow amount: light moderate heavy Cramping: mild moderate severe OB Medical History (circle all that apply) Blood antibody sensitization Gestational diabetes History of fetal distress in labor History of Group B Strep Low/High Amniotic fluid Placenta previa Placental abruption Preeclampsia/High BP Prior C-section Prior infant admitted NICU Prior infant over 9 lbs Recurrent bladder infections Recurrent miscarriages Stillbirth/Neonatal death Twin/Triplet pregnancy Obstetrical History Total pregnancies Full term deliveries PreTerm deliveries Miscarriages Abortions Living children ______ ______ ______ ______ ______ ______ Medications: If you take herbal supplements or over the counter medications, please list below. Medication Dose Directions Doctor Family History (circle all that apply) Birth defects Depression Diabetes Endometriosis Heart disease Ovarian cancer Cervical cancer Thyroid cancer Other __________________ High blood pressure Multiple births Seizure disorder Stroke syndrome Breast cancer Endometrial (uterine) cancer Colon cancer Melanoma OB Family Genetic Review (circle all that apply) Anencephaly/Hydrocephaly Birth defects Cystic Fibrosis Down Syndrome Genetic Disorder Hemophilia Huntington chorea Muscular Dystrophy Sickle cell disease Spina Bifida Tay Sachs Thalassemia OB Risk Factors (circle all that apply) Mother’s age less than 10 or over 35 Prior preterm birth 2 miscarriages requiring D&C Psychosocial/Physical abuse Black Race Weight less than 120 lbs Please turn over and complete second page. History of STD Incompetent cervix Prior uterine surgery DES exposure Drug/Alcohol/Tobacco use Known uterine malformation SOUTHERN UTAH WOMEN’S HEALTH CENTER, PC HEALTH INFORMATION Past Pregnancy Details (please complete for all pregnancies including miscarriages) Birth Date Length of pregnancy (weeks) Hours Of Labor Birth Weight (lb/oz) Sex Type Of Delivery Anesthesia Location Complications
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