Formulario de Historia Médica

Gracias por fijar una cita con las parteras de BetterBirth. Necesitamos revisar su historia médica para asegurarnos que usted es buena candidata para los servicios que proveemos. Por favor, llene este formulario y sométalo electronicamente (instrucciones abajo). ¡Esperamos conocernos pronto!

Tenga cuidado en no apretar la tecla “Enter”. A veces hace que el formulario se somete solo sin que termine de llenarlo.

    Madre de Este Bebé

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    Padre de Este Bebé

    Estas preguntas pertenecen al padre de este bebé.
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    Seguro Médico

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    Historia Médica General

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    Dieta

    Seleccione las opciones que mejor describen su dieta.
    Tomo un suplemento de vitaminas:
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    Elijo los alimentos por su contenido nutricional:
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    Yo como buenas fuentes de proteínas:
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    Yo como frutas y verduras frescas (o ligeramente cocidas):
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    Los granos que como son:
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    Como alimentos procesados​​:
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    En general:
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    Historia Ginecológica

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    Embarazo Actual

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    Preferencias de Nacimiento y Experiencias

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    Embarazos Anteriores

    A continuación se pregunta sobre sus embarazos anteriores. Por favor, conteste una serie de preguntas por cada embarazo, incluyendo abortos involuntarios, mortinatos, abortos, y los óvulos deteriorados, así como nacidos vivos. Por supuesto, si el embarazo no se tradujo en un nacimiento vivo, algunas de las preguntas no se aplicarán, por lo que deje en blanco para ese embarazo. Lo importante es que podamos saber cada vez que usted ha estado embarazada antes de este embarazo, sin importar el resultado. Por favor NO RESPONDER POR EL EMBARAZO ACTUAL. Esta sección es para embarazos anteriores SOLAMENTE. Hay espacio en esta forma para 4 embarazos anteriores. Si usted ha estado embarazada más de 4 veces, llenar la información de los 4 primeros embarazos, y nos informa cuando llega a la cita que tiene más embarazos para agregar. Contestar las primeras 5 preguntas ("Fecha en que Terminó el Embarazo", "Gestación", "Resultado", "Complicaciones del Embarazo" y "Nombre del Bebé") para todos los embarazos. Responder a las preguntas restantes sólo para los embarazos que continúaron después de 20 semanas de gestación. Si este es su primer embarazo, no tome las siguientes preguntas en este formulario. Desplácese hasta la parte inferior y haga clic en "Submit".

    Embarazo 1

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    Embarazo 2

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    Embarazo 4

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    Más Embarazos Anteriores

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    ¡Es Todo!

    Haga click en el botón "Submit" abajo para someter el formulario. Se debe ver "Thanks, your response has been recorded." Si no lo vea, puede que haya faltado de contestar alguna pregunta requirida. Revise las preguntas y sus respuestas hasta completarlas todas. Si tenga preguntas antes de su cita, llamenos a 877-783-0183. ¡Nos vemos pronto!