PRENATAL INTERVIEW FORM
This information will be kept in our files for office use only. If you choose our doctors as your primary care
physicians, this information will become part of your child’s permanent record in our office.
Today’s Date _______________________ Estimated Delivery Date ________________________
Father’s Last Name (please print) First Name Initial
Mother’s Last Name (please print) First Name Initial
Where will baby be delivered? (HOSPITAL) ______________________ OB/GYN______________________
Mother: Have you had breast surgery? Yes ? No ?
Did you take hormones or medicines during pregnancy? Yes ? No ?
Did you drink alcohol or smoke during pregnancy? Yes ? No ?
Do you have any history of vaginal group B strep? Yes ? No ?
Do you or the father have any history of STD’s (gonorrhea, chlamydia, trichomoniasis)? Yes ? No ?
Do you intend to breast feed your baby? Yes ? No ?
Do you have an infant car seat that meets current safety standards? Yes ? No ?
Any history in baby’s close relatives (grandparent, sibling, aunt, uncle) of: (please check appropriate items)
___Interrupted Pregnancies ___HIV/AIDS ___Birth Defects ___Kidney Disease ___Substance Abuse
___Tuberculosis ___Diabetes ___Chemotherapy ___Thyroid Disease ___Other
___Allergies ___High Cholesterol ___Bleeding Tendencies ___Liver Disease
___Convulsions/Epilepsy ___High Blood Pressure ___Sudden/UnexpectedDeath ___Mental or Emotional Problems
___Other Heart Disease ___Early Heart Attacks or fatality from illness ___Cancer
Other Children? (Please list name, age and gender)________________________________________________
Whom may we thank for referring you to our practice? _____________________________________________Please list any other information you think we should know on the back of this page.