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.
First Name *
Enter your current legal first name.
Your answer
Middle Name
Enter your middle name AS GIVEN AT YOUR BIRTH. Please do NOT enter your maiden name as the middle name, even if your maiden name is your current legal middle name.
Your answer
Last Name *
Enter your current legal last name.
Your answer
Practice
Sorry to interrupt...Which care provider are you using for this pregnancy?
Maiden Name
Enter your last name prior to your first marriage (usually your last name as given at birth). If this name is the same as the last name you entered above, please re-enter it here so we know.
Your answer
Goes By
Enter the name you prefer to be called. For example, if your name is Catherine, you may prefer to be called "Cathy." In that case, you would enter "Cathy" here. If you prefer to be called by your legal first name, re-enter that name here.
Your answer
Date of Birth *
Enter your date of birth like this: MM/DD/YYYY. For example, if you were born April 9, 1987, you would enter "04/09/1987".
Your answer
Country of Birth
Enter the country in which you were born. If you were born in the United States, enter "USA".
Your answer
State of Birth
Select the US state or territory in which you were born. If you were born outside the USA, leave this question blank.
Social Security Number
Enter your Social Security Number. This information is used to file your baby's birth certificate and request a social security card for the baby from the Social Security Administration.
Your answer
Height
Enter your height in feet and inches. For example: 5' 4". If you prefer, you may enter your height in meters: "1.8m"
Your answer
Education
Select the option that best describes the highest level of education you have completed.
Degree Field
If you completed a college or graduate degree, in what field?
Your answer
Residence Address
Enter the street portion of the address of your residence. For example, "123 N Maple St, Apt 5"
Your answer
Residence City
Enter the city in which you live, for example: "Salt Lake City" or "Provo"
Your answer
Residence State
Select the US state or territory in which you live. If you live outside the USA, leave this question blank.
Residence Zip Code
Enter the zip code of your residence. If you live outside the USA, enter the appropriate postal code for your residence.
Your answer
Residence Country
Enter the country (that is, the NATION) in which you live. If you live in the United States, enter "USA".
Your answer
Residence County
Enter the county (that is, the PART OF YOUR STATE) you live in. For example, "Wasatch", "Iron", "Summit", "Juab", "Utah", "Salt Lake", "Tooele".
Your answer
Within City Limits?
Select from the list whether your home lies within city limits ("Yes"), or outside city limits ("No").
Mailing Same As Residence?
Select from the list whether your maiing address is the same as your residential address ("Yes"), or if you have a separate mailing address ("No").
Mailing Address
Enter the street portion of your mailing address. For example, "123 N Maple St", or if you receive your mail at a post office box, enter the box number" "PO Box 123". If your mailing address is the same as your residence address, leave this question blank.
Your answer
Mailing City
Enter the city of your mailing address. If your mailing address is the same as your residence address, leave this question blank.
Your answer
Mailing State
Select the US state or territory of your mailing address. If your mailing address is outside the USA or if your mailing address is the same as your residence address, leave this question blank.
Mailing Zip Code
Enter the zip code of your mailing address. If your mailing address is outside the USA, enter the appropriate postal code for your mailing address. If your mailing address is the same as your residence address, leave this question blank.
Your answer
Mailing Country
Enter the country of your mailing address. If your mailing address is in the United States, enter "USA". If your mailing address is the same as your residence address, leave this question blank.
Your answer
Cell Phone
Enter your cell phone number like this: 801 555-5555. If you do not have a cell phone, leave this question blank.
Your answer
Home Phone
Enter your home phone number like this: 801 555-5555. If you do not have a home phone, leave this question blank.
Your answer
Work Phone
Enter your work phone number like this: 801 555-5555. If you do not have a work phone, leave this question blank.
Your answer
E-Mail Address *
Enter the e-mail address where we may correspond with you. We do not share your e-mail address with ANYONE, and we don't send you any marketing or spammy e-mails. We do use it to confirm appointments, send you test results, and otherwise convey important information about your care. Please review your entry for accuracy.
Your answer
Occupation
Enter your occupation. For example, "Teacher," "Software Engineer," "Homemaker."
Your answer
Marital Status
Select your marital status.
Blood Type
Select your blood type from the list.
Religious Preference
Select your religious preference from the list.
Sexual Orientation
Select your sexual orientation from the list.
Race
Check the box(es) that best describe your race.
Tribal Affiliation
If you selected "American Indian or Alaskan Native" above, specify your tribal affiliation. If you did not select one of these options in the previous question, leave this question blank.
Your answer
Hispanic
If you are Hispanic/Latina, specify your origin.
Partner Information
Enter information about the father of this baby (if pregnant)/partner (if not pregnant).
First Name
Enter the legal first name of the father of this baby (if pregnant)/partner (if not pregnant).
Your answer
Middle Name
Enter the legal middle name of the father of this baby (if pregnant)/partner (if not pregnant).
Your answer
Last Name
Enter the legal last name of the father of this baby (if pregnant)/partner (if not pregnant).
Your answer
Suffix
Enter any suffix that is part of the legal name of the father of this baby/partner, for example "Jr", "III". If none, leave this question blank.
Your answer
Goes By
Enter the name the father of this baby/your partner prefers to be called. For example, if his name is "Stephen" he may prefer to be called "Steve." In that case, you would enter "Steve" here. If he prefers to be called by his legal first name, re-enter that name here.
Your answer
Date of Birth
Enter the date of birth of the father of this baby/your partner, like this: MM/DD/YYYY. For example, if he was born April 9, 1987, you would enter "04/09/1987".
Your answer
Country of Birth
Enter the country where the father of this baby/your partner was born. If he was born in the United States, enter "USA".
Your answer
State of Birth
Select the US state or territory in which the father of this baby/your partner was born. If he was born outside the USA, leave this question blank.
Social Security Number
Enter the social security number of the father of this baby/your partner. This information is used to file your baby's birth certificate and request a social security card for the baby from the Social Security Administration.
Your answer
Race
Check the box(es) that best describe the race of the father of this baby/your partner.
Tribal Affiliation
If you selected "American Indian or Alaskan Native" above, specify the tribal affiliation of the father of this baby/your partner. If you did not select one of these options in the previous question, leave this question blank.
Your answer
Hispanic
If the father of this baby/your partner is Hispanic/latino, enter his origin.
Education
Select the option that best describes the highest level of education the father of this baby/your partner has completed.
Father's Mailing Same as Mothers?
Is the father or this baby's/your partner's mailing address of the same as the mother's mailing address?
Mailing Address
Enter the street portion of the father's/your partner's mailing address. For example, "123 N Maple St", or if he receives his mail at a post office box, enter the box number" "PO Box 123". If his mailing address is the same as your mailing address, leave this question blank.
Your answer
Mailing City
Enter the city of the father's/your partner's mailing address. If his mailing address is the same as your mailing address, leave this question blank.
Your answer
Mailing State
Select the US state or territory of the father of this baby's/your partner's mailing address. If his mailing address is outside the USA or if his mailing address is the same as your mailing address, leave this question blank.
Mailing Zip Code
Enter the zip code of the father of this baby's/your partner's mailing address. If his mailing address is the same as your mailing address, leave this question blank.
Your answer
Mailing Country
Enter the country of the father's/your partner's mailing address. If his mailing address is in the United States, enter "USA". If his mailing address is the same as your mailing address, leave this question blank.
Your answer
Cell Phone
Enter the cell phone number of the father of this baby/your partner like this: 801 555-5555. If none, leave this question blank.
Your answer
Home Phone
Enter the home phone number of the father of this baby/your partner like this: 801 555-5555. If none, leave this question blank.
Your answer
Work Phone
Enter the work phone number of the father of this baby/your partner like this: 801 555-5555. If none, leave this question blank.
Your answer
E-Mail Address
Enter the e-mail address of the father of this baby/your partner. Please review your entry for accuracy.
Your answer
Occupation
Enter the occupation of the father of this baby/your partner. For example, "Teacher", "Software Engineer", "Homemaker".
Your answer
Insurance
Insurance Status
Select your insurance status. If you select anything except "Other Insurance", skip the rest of the questions in the Insurance section.
Insurance Company
Enter the name of your health insurance company, for example: "SelectHealth", "Blue Cross Blue Shield", "DMBA", etc.
Your answer
Policyholder
Select the primary policyholder for this insurance.
Maternity Coverage
Do you have maternity coverage with this insurer? (That is, does your insurance cover pregnancy and delivery?)
Deductible
Enter your deductible with this policy. The deductible is the amount you must pay each year before the insurance will pay anything.
Your answer
Skip
Please skip this question.
Your answer
General Medical
Medications
If you currently take any medications, list them here. If you do not take any medications, leave this question blank.
Your answer
Medication Allergies
If you have ever had a bad reaction to a medication, whether prescription or over-the-counter, list the medications and describe the reaction you had to each one. If you have never had a bad reaction to a medication, leave this question blank.
Your answer
Surgeries
Mark any of the following surgeries you have had. If you have not had any, do not mark any. NOTE: "Uterine surgery" does NOT include C-section. Only mark this item if you have had other kinds of surgery on your uterus, such as surgery to remove a fibroid. Examples of cervical surgery are LEEP and cone biopsy. Breast surgery includes augmentation and reduction.
Describe Surgery
If you marked any of the surgeries in the previous question, describe the surgery you had, and the year(s) you had it.
Your answer
Underlying Conditions
Mark any of the following underlying conditions you may have. If you do not have any of these conditions, do not mark any.
Describe Underlying Conditions
If you checked any conditions in the previous question, describe your condition(s) and any information we should know about them, including any medications you may take for them.
Your answer
Family History of Diabetes
Is there a history of diabetes in your immediate family? (Immediate family includes your parents, grandparents, siblings, and children.)
Describe Family History Diabetes
If you answered "Yes" to the previous question, list which family members have/had diabetes and what type.
Your answer
Preexisting Diabetes
Do you have diabetes when not pregnant?
Infectious Disease
Check any of the following conditions you have.
Psychological Disorders
Mark any of the following psychological disorders you may have.
Describe Psychological Disorders
If you checked any boxes in the previous question, describe your psychological condition (including any medications you currently take for it).
Your answer
Domestic Violence
Are you currently a victim of domestic violence?
Sexual Assault/Abuse
Have you ever been a victim of sexual assault or abuse?
Effect of Abuse
If you answered "Yes" to the previous question, enter any concerns you have about the effect of the assault or abuse on your pregnancy or delivery. If none, leave this question blank.
Your answer
Smoking
How many cigarettes per day (on average) did you smoke during the three months prior to becoming pregnant (if pregnant), or during the last three months(if not pregnant)? If you do not smoke, enter "0".
Your answer
Alcohol
How many drinks per week (on average) did you consume during the three months prior to becoming pregnant (if pregnant), or during the last three months (if not pregnant)? If you do not drink alcohol, enter "0".
Your answer
Substance Abuse
Do you abuse any substances?
Other Issues
If you have any other health issues of which we should be aware, describe them here.
Your answer
Diet
Select the options that best match your diet.
Vitamins & MInerals
Daily
Frequently
Occasionally
Never
I take a vitamin supplement:
General
Almost always
Often
Sometimes
Seldom
I choose foods for their nutritional content:
Protein
At least 3 times daily
At least once daily
At least a few times per week
Seldom
I eat good protein sources:
Fruits & Vegetables
At least 3 servings daily
At least 1 serving daily
At least a few times per week
Seldom
I eat fresh (or lightly cooked) fruits and vegetables:
Grains
Always whole grain never white
Usually whole grain sometimes white
Usually white seldom whole grain
Always white never whole grain
The grains I eat are:
Processed Foods
Less than once a week
Several times a week
Daily
As my primary diet
I eat processed foods:
Calories
I eat when I'm hungry and am satisfied when done. I easily maintain my weight.
I skip meals occasionally but I can usually maintain my weight.
I skip meals several times a week and easily lose weight.
I often go hungry and I struggle to maintain my weight.
In general:
Gynecologic History
Reproductive Organ Problems
If you have had problems with any of the following, please mark:
Describe Reproductive Organ Problems
If you marked any boxes in the previous question, describe the problems.
Your answer
Contraception
Mark any of the following forms of birth control you have used.
Contraception Problems
Describe any problems you have had with these methods of contraception. If none, leave this question blank.
Your answer
Pap Smear
When was your last pap smear?
Pap Smear Result
What was the result of your last pap smear?
Irregular Pap Smear
If you answered "Irregular" to the last question, describe the irregularity and any actions taken.
Your answer
Menarche
How old were you when you had your first period? Enter a number of years, for example: "12"
Your answer
Regularity of Menses
How would you describe the frequency of your periods?
Cycle Length
How often do you have a period? For example, if you have a period every 28 days, enter "28". If your periods are irregular, enter a range of days, for example: "26-40".
Your answer
Period Length
For how long do you bleed when you have a period? For example, if you bleed for 5 days, enter "5". If the length of your period varies, enter a range of days, for example: "3-6".
Your answer
LMP
Enter the date of the first day of your last menstrual period, like this: MM/DD/YYYY. If the date was April 5, 2011, you would enter "04/05/2011". If you don't know the date, enter "Unknown".
Your answer
Period Normal
Was your last period normal? If your period was typical of other periods in both its timing and character (such as length and amount of bleeding), enter "Yes". If this period was significantly different from normal, enter "No" and describe in what way it was abnormal.
Your answer
Date Certainty
Are you certain of the date of the first day of your last menstrual period?
Error Margin
If you answered "No" to the previous question, how far off could you be? If you think you could be off by as much as 10 days, enter "10 days". If you think you could only be off by 2 days, enter "2 days".
Your answer
This Pregnancy
Pregnant Now?
Are you pregnant now? If you answer "No" to this question, skip the rest of the questions in this section and continue with the "Birth Preferences and Experiences" section below.
Conception Date
Do you know the date you conceived (or ovulated)? If so, enter it here like this: MM/DD/YYYY. For example, if you conceived on April 5, 2011, enter "04/05/2011". If you do not know the date you conceived, leave this question blank.
Your answer
Last Negative Test
If you took a pregnancy test, enter the last date you took a test whose result was negative (indicing "not pregnant"), like this: MM/DD/YYYY. If you did not take a pregnancy test or if all tests you took were positive (indicating "pregnant"), leave this question blank.
Your answer
First Positive Test
If you took a pregnancy test, enter the first date you took a test whose result was positive (indicating "pregnant"), like this: MM/DD/YYYY. If you did not take a pregnancy test or if all tests you took were negative (indicating "not pregnant"), leave this question blank.
Your answer
Ultrasounds
If you have had any ultrasounds (sonograms) this pregnancy, list them below. For each one include 1) the date of the ultrasound, 2) where you had the ultrasound performed, 3) the due date given based on the ultrasound, and 4) any important findings. For example: "3/11/2011 at St Marks Hospital gave due date of 9/18/2011 and showed low-lying placenta."
Your answer
Pre-Pregnancy Weight
Enter your weight before you became pregnant. If you do not know (or cannot closely estimate) your pre-pregnancy weight, enter "Unknown".
Your answer
Planned Pregnancy
Was this pregnancy planned?
Difficulty Conceiving
Did you have difficulty conceiving?
How Long Trying
How long did you try to conceive before becoming pregnant? If this pregnancy was not planned, select "0-5 months".
Method of Conception
What method did you use to conceive? "Coitus" is sexual intercourse. "In vitro" is conception that occurs in a laboratory dish and is later transferred to the uterus. "Artificial insemination" is where semen is placed in your vagina or uterus NOT by sexual intercourse.)
Infertility Treatments
Mark any of the following infertility treatments you used to help you conceive or maintain the pregnancy.
Gestational Carrier
Are you serving as a gestational carrier? (Also known as a "surrogate" where you carry the baby for someone else.)
Previous Provider
If you have already received any care for THIS pregnancy from another provider, enter the date of your first visit with the first provider like this: MM/DD/YYYY. If you don't know the exact date, enter as much as you know, for example "04/2011".
Your answer
Visits with Previous Provider
If you have already received care for THIS pregnancy from another provider, enter the number of visits with all previous providers this pregnancy. For example, if you have had 3 visits so far, enter "3".
Your answer
Birth Preferences & Experiences
Reasons for Choosing Out-of-Hospital Birth
Check any of the following reasons you have for choosing (or exploring) out-of-hospital birth.
Planned Venue
Where are you planning to give birth?
Negative Previous Experience
If you have been pregnant previously or seen another provider this pregnancy, is there anything you did NOT like about those previous providers or experiences? If so, explain here.
Your answer
Positive Previous Experience
If you have been pregnant previously or seen another provider this pregnancy, is there anything you especially LIKED about those previous providers or experiences? If so, explain here.
Your answer
Concerns
Do you have any concerns about this pregnancy or birth? If so, describe here.
Your answer
Desires This Birth
Is there anything you especially want this pregnancy or birth? If so, describe here.
Your answer
Avoid This Birth
Is there anything you especially want to avoid this pregnancy or birth? If so, describe here.
Your answer
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
Pregnancy #1:Date Pregnancy Ended
Enter the date the pregnancy ended, like this: MM/DD/YYYY. For example, if you miscarried or gave birth april 5, 2001, enter "04/05/2001". If you are not sure of the date, enter what you know. For example, if you know you had a miscarriage in February of 2000, enter "02/2000". If you only know the year, just put the year. Try to be as specific as you can.
Your answer
Pregnancy #1:Gestation
Enter how many weeks along you were when the pregnancy ended. At your due date, you would be 40 weeks along. If you delivered 1 week late, enter "41". If you miscarried at 7 weeks, enter "7".
Your answer
Pregnancy #1:Outcome
Select the outcome of this pregnancy.
Pregnancy #1:Pregnancy Complications
Mark any of the following complications you experienced with this pregnancy. If you did not have any of these complications, do not mark any.
Pregnancy #1:Name of Baby
If you named this baby, enter the name here. If this pregnancy ended prior to 20 weeks gestation, this is the last question for this pregnancy. Skip to the next pregnancy, or to the end of the form if this was your last previous pregnancy. If this was a multiple pregnancy (twins or triplets), answer only for the first baby.
Your answer
Pregnancy #1:Gender
Select the gender of this baby. If this was a multiple pregnancy (twins or triplets), answer only for the first baby.
Pregnancy #1:Birthweight Pounds
Enter the "pounds" portion of what this baby weighed at birth. For example, if the baby weighed 6 lbs 4 oz, enter "6". You will enter the ounces in the next question. If this was a multiple pregnancy (twins or triplets), answer only for the first baby.
Your answer
Pregnancy #1:Birthweight Ounces
Enter the "ounces" portion of what this baby weighed at birth. For example, if the baby weighed 6 lbs 4 oz, enter "4". If this was a multiple pregnancy (twins or triplets), answer only for the first baby.
Your answer
Pregnancy #1:Weight Gain
Enter how much weight you gained during this pregnancy, in pounds. For example, if you gained 35 pounds, enter "35".
Your answer
Pregnancy #1:GD Status
Select from the list your gestational diabetes status during this pregnancy.
Pregnancy #1:GBS
Did you test positive for Group B Strep (also called "Strep B", "GBS+" or "GBS positive")?
Pregnancy #1:Provider
Who cared for you during this pregnancy? (Please include title. For example: "Dr. John Smith, OB/GYN", "Maxine Waters, CNM", "Suzanne Smith, LDEM", "Jane Doe, midwife".)
Your answer
Pregnancy #1:Delivery Venue
Where did you deliver this baby?
Pregnancy #1:Length of Labor
How many hours were you in labor? For example, if you were in labor 16 hours, enter "16". If this delivery was a planned c-section and you never labored, enter "0".
Your answer
Pregnancy #1:Labor Onset
How did this labor start? If this delivery was a planned or unplanned c-section and you never labored, select "N/A".
Pregnancy #1:Induction Methods
If you selected "Induced" in the previous question, mark all the methods of induction that were attempted to start this labor.
Pregnancy #1:Augmentation
You have already indicated whether Pitocin was used to start your labor. Did you receive Pitocin after labor began to make contractions stronger?
Pregnancy #1:Pain Relief
Did you receive an epidural (or other spinal pain relief) during this labor? If you had a c-section and only had the epidural or spinal for the surgical part of the delivery (that is, not during the labor that preceded it), select "No".
Pregnancy #1:ROM Timing
When did your bag of waters break?
Pregnancy #1:ROM Method
How did your bag of waters break?
Pregnancy #1:ROM Length
For how long was your bag of waters broken?
Pregnancy #1:Mode of Delivery
How was this child born?
Pregnancy #1:Pushing
If this baby was delivered vaginally, how long did you push? For example, "2 hrs", "30 min", "3:10" (which means "3 hrs 10 min"). If you delivered by c-section, leave this question blank.
Your answer
Pregnancy #1:Episiotomy
If this baby was delivered vaginally, did you receive an episiotomy (a cut to enlarge the vaginal opening) during this delivery? If you delivered by c-section, leave this question blank.
Pregnancy #1:Perineal Injury
If this baby was delivered vaginally, what type of injury occurred to your perineum (vaginal opening)? Tears that do not extend into the anal sphincter/rectum are 1st-2nd degree. Tears into the anal sphincter/rectum are 3rd-4th degree. For purposes of this question, consider a cut the same as a tear. If you did not have any injury, select "No tear". If you delivered by c-section, leave this question blank.
Pregnancy #1:Incision Type
If this baby was delivered by c-section, what type of incision (cut) did you have? If you delivered vaginally, leave this question blank.
Pregnancy #1:C-Section Timing
If this baby was delivered by c-section, when was the c-section performed? If you delivered vaginally, leave this question blank.
Pregnancy #1:C-Section Reason
If this baby was born by c-section, what was the primary reason the c-section was performed? If you delivered vaginally, leave this question blank.
Pregnancy #1:Labor Complications
Mark any of the following complications you experienced during the labor or delivery of this baby. If you did not experience any, do not mark any.
Pregnancy #1:Significant Features
Please tell us any significant features of this pregnancy, labor, delivery, or post-delivery period.
Your answer
Pregnancy #2
Pregnancy #2:Date Pregnancy Ended
Enter the date the pregnancy ended, like this: MM/DD/YYYY. For example, if you miscarried or gave birth april 5, 2001, enter "04/05/2001". If you are not sure of the date, enter what you know. For example, if you know you had a miscarriage in February of 2000, enter "02/2000". If you only know the year, just put the year. Try to be as specific as you can.
Your answer
Pregnancy #2:Gestation
Enter how many weeks along you were when the pregnancy ended. At your due date, you would be 40 weeks along. If you delivered 1 week late, enter "41". If you miscarried at 7 weeks, enter "7".
Your answer
Pregnancy #2:Outcome
Select the outcome of this pregnancy.
Pregnancy #2:Pregnancy Complications
Mark any of the following complications you experienced with this pregnancy. If you did not have any of these complications, do not mark any.