History Form

As part of our initial appointment we like to review your medical history to ensure you are an appropriate candidate for the care we provide. Please fill out the following form and submit it electronically. If there is any question you do not understand or do not wish to answer, leave it blank. We know the form is long, and we thank your for your effort in filling it out. We promise it will save you a lot of form-filling time at your appointment. We look forward to meeting with you soon!

BE CAREFUL not to press the Enter key as it may cause the form to submit prematurely. Also, it is more reliable to submit via computer than phone.

    Client Information

    Refers to the person who will be receiving care from us, whether pregnant or not. Partner information will be entered in the next section.
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    Partner Information

    Enter information about the father of this baby (if pregnant)/partner (if not pregnant).
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    Insurance

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    General Medical

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    Diet

    Select the options that best match your diet.
    I take a vitamin supplement:
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    I choose foods for their nutritional content:
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    I eat good protein sources:
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    I eat fresh (or lightly cooked) fruits and vegetables:
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    The grains I eat are:
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    I eat processed foods:
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    In general:
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    Gynecologic History

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    This Pregnancy

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    Birth Preferences & Experiences

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    Previous Pregnancies

    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".

    Pregnancy #1

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    Pregnancy #2

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    Pregnancy #3

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    Pregnancy #4

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    More Previous Pregnancies

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    You're Done!

    Click "Submit" below to submit your history form to us. You should see "Thanks, your response has been recorded." If you do not, you may have omitted some required questions. Scroll to the top to check. If you have any questions before your appointment, give us a call at (801) 225-5668. We'll see you soon!