Prenatal Questionaire
 
 

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 ________________________

 

NAME___________________________________________________________________________

            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______________________

 

FAMILY HISTORY

 

 

  Birth Date

 Height

Weight

      Medical Problems

Education Level

Father

 

 

 

 

 

Mother

 

 

 

 

 

Mother: Have you had breast surgery?                                               Yes ? No ?

              Did you take hormones or medicines during pregnancy?     Yes ? No ?

              (Explain) __________________________________________________________________________

              Did you drink alcohol or smoke during pregnancy?             Yes ? No ?

              Do you have any history of vaginal group B strep?                         Yes ? No ?

              (Explain) __________________________________________________________________________

              Do you or the father have any history of STD’s (gonorrhea, chlamydia, trichomoniasis)? Yes ?  No  ?

        (Explain)___________________________________________________________________________

              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.