Below are questions regarding your previous pregnancies. Please answer a set of questions for EVERY PREGNANCY, including miscarriages, stillbirths, abortions, and blighted ova as well as live births. Of course, if the pregnancy did not result in a live birth, some of the questions will not apply, so leave them blank for that pregnancy. The important thing is that we account for every time you have been pregnant, regardless of the outcome. Please DO NOT ANSWER FOR THE CURRENT PREGNANCY. This section is for PAST PREGNANCIES ONLY. There is space in this form for 4 past pregnancies. If you have been pregnant more than 4 times, fill out the information for the first 4 pregnancies, and inform us when you come in for your appointment that you have more pregnancies to record.
Answer the first 5 questions ("Date Pregnancy Ended", "Gestation", "Outcome", "Pregnancy Complications", and "Name of Baby") for all pregnancies. Answer the remaining questions only for pregnancies that continued past 20 weeks gestation.
If this is your FIRST PREGNANCY, skip the remaining questions on this form. Scroll down to the bottom and click "Submit".