Obstetrics & Gynecology of North Texas, LLP

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Patient's Name Please provide a name

Partner's Name

Physician Please select a physician

Preferred Pharmacy

Referred By

Date of Birth Please select a date

Patient's Height

Is there a history of maternal metabolic disorder, such as, Diabetes Mellitus or PKU?

Yes No

Are you or the baby's father, Asian (from SE Asia, China, Taiwan, Philippines, India), Greek, Italian, or Middle Eastern?

Yes No

Have you, the baby's father, or anyone in your families been diagnosed with a neural tube defect (open spine, spine bifida, anencephaly)?

Yes No

Have you, the baby's father, or anyone in either of your families had a pregnancy or a child diagnosed with Down Syndrome?

Yes No

Are you or the baby's father Jewish or french Canadian? If yes, has either of you been tested to see if you are a carrier of Tay-Sachs Disease or Canavan's Disease?

Yes No

Are you or the baby's father Latino or African American? If yes, has either of you been tested to see if you are a carrier of sickle cell disease?

Yes No

Do you, the baby's father, or anyone in either of your families have hemophilia, muscular dystrophy, or Hydrocephalus?

Yes No

Do you, the baby's father, or anyone in either of your families have cystic fibrosis?

Yes No

Do you, the baby's father, or anyone in either of your families have Huntington's disease?

Yes No

Do you, the baby's father, or anyone in either of your families have a history of autism, learning disabilities or mental retardation?

Yes No

Do you, the baby's father, or anyone in either of your families have an inherited disorder or chromosome abnormality not listed above?

Yes No

Do you, the baby's father or anyone in either of your families have a birth defect (congenital heart defect, deft lip, etc.) not listed above?

Yes No

Have you or the baby's father had a stillborn child or three or more first trimester miscarriages in this or any other relationship?

Yes No

Have you taken any medications or recreational drugs, or alcoholic drinks since your last menstrual period?

Yes No

Will you be 35 or older when the baby is due?

Yes No

Are there cats in the home?

Yes No

Do you have close contact with children on a regular basis?

Yes No

Have you had chicken pox?

Yes No

Do you, or someone you live with, have tuberculosis or been exposed?

Yes No

Have you had an unexplained rash or a viral illness since your last period?

Yes No

Do you or your partner have a history of genital herpes?

Yes No

Do you feel safe in your current relationship?

Yes No

Do you or the baby's father have any concerns about any other conditions in either of your families?

Yes No

Medical History (Please select all that apply)
Alcoholism	Cancer (If yes, what kind?)	Genetic Condition	Mitral Valve Prolapse
Anemia	Chicken Pox	Heart Attack	Osteoarthritis
Anxiety	Depression	Heart Disease	Pelvic Infections
Asthma	Diabetes Type I	High Blood Pressure	Pneumonia
Autoimmune Disease	Diabetes Type II	High Cholesterol	Rheumatoid Arthritis
Bladder Infections	Drug Dependence	Hyperthyroidism	Seizures
Bleeding Problems	Eating Disorders	Hypothyroidism	Sickle Cell Anemia
Blood Clot in Legs	Epilepsy	Kidney Infection	Stroke
Blood Clot in Lungs	Esophageal Reflux	Liver Disease	Tuberculosis
Blood Transfusions	Gallbladder Disease	Migraine

Have you ever had any of the following STDs?
Chlamydia		Gonorrhea		Hepatitis B/Hepatitis C		Herpes
HIV		HPV		Syphilis		Trichomoniasis

	Results
Last Blood Work	Normal	Abnormal
Last Bone Density	Normal	Osteopenia Osteoporosis	Never had one
Last Colonoscopy	Normal	Abnormal	Never had one
Last Mammogram	Normal	Abnormal	Never had one
Last PAP Smear	Normal	Abnormal	Never had one

Have you ever needed any of the following for an abnormal PAP Smear? (Select all that apply)
Colposcopy		Cryosurgery		LEEP/Laser conization		None

Have you ever had any of the following?
Endometriosis		Fibrocystic breasts		Ovarian Cyst		Uterine fibroids

Gynecology surgery history
Please list all surgery relating to female reproductive system, year and reason

Surgical history
Please list all surgeries with date

Medications
List ALL medications you are currently taking, including over the counter medications, vitamins and herbal remedies
Include prescribing physician if applicable and dose/frequency if known

Allergies
List any allergies to medications, including reactions

If no known drug allergies, please put your initials here

Other Allergies
List any other allergies: food, environment, etc.

Family History Please list any close relatives with history of the following
Condition	Relative	Side of Family	Age at Diagnosis	Notes
Breast Cancer		Mother Father Unknown
Colon Cancer		Mother Father Unknown
Diabetes Type 1		Mother Father Unknown
Diabetes Type 2		Mother Father Unknown
Heart Disease		Mother Father Unknown
High Blood Pressure		Mother Father Unknown
Ovarian Cancer		Mother Father Unknown
Stroke		Mother Father Unknown
Uterine Cancer		Mother Father Unknown

Obstetrical History
Have you ever been pregnant?	Yes	No
Have you adopted children?	Yes	No

Pregnancy History
Name	Age	Date	Length of Pregnancy	Birth Weight	M/F	Type of Delivery	Anesthesia	Early Labor?	Complications?
					M F			Y N	Y N
					M F			Y N	Y N
					M F			Y N	Y N
					M F			Y N	Y N

Gynecological History
First Day of Last Menstrual Period
How long did it last?
Flow?	Regular	Moderate	Heavy
Periods are?	Regular	Irregular	Painful	Light
Method of birth control?	Condoms	Pills	Depo	IUD
	Vaginal Ring	Tube Ligation	Partner with Vasectomy	Natural Family Planning
	Other

Social History
Occupation
Marital Status	Single	Married	Separated	Divorced	Widowed
Alcohol Use	Yes	No
Tobacco Use	Yes	No
Recreational Drug Use	Yes	No

Exercise	Yes	No

Caffeine	Yes	No
Sexual Abuse	Yes	No
	Are you safe now?	Yes	No	Need Counselling?	Yes	No
Physical Abuse	Yes	No
	Are you safe now?	Yes	No	Need Counselling?	Yes	No
Emotional Abuse	Yes	No
	Are you safe now?	Yes	No	Need Counselling?	Yes	No

Review of Systems
Constitutional	Fever	Fatigue
Eyes	Double Vision	Spots Before Eyes
Ear, Nose and Throat	Earaches	Sore Throat
Breasts	Nipple Discharge	Lumps
Cardiovascular	Chest Pain or Pressure	Rapid or Irregular Heartbeat
Respiratory	Shortness of Breath	Chronic Cough
Gastrointestinal	Frequent Diarrhea	Constipation
Genitourinary	Blood in Urine	Pain with Urination	Involuntary Urine Loss	Abnormal Bleeding
	Painful Periods	Premenstrual Syndrome (PMS)	Abnormal Vaginal Discharge	Painful Intercourse
Skin	Rash	Moles (Growth/Changes)
Neurologic	Dizziness	Frequent Headaches
Musculoskeletal	Muscle Weakness	Muscle or Joint Pain
Endocrine	Hair Loss	Hot Flashes
Psychiatric	Depression or Frequent Crying	Anxiety
Hematologic/Lymphatic	Frequent Bruising	Enlarged Lymph Nodes (Glands)

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