Patient Information & Pregnancy Questionnaire



PATIENT INFORMATION & PREGNANCY QUESTIONNAIRE


First Name*:

Last Name*:

Date of Birth:

Address:

City:

State:

Zip:

Counrty (CA only):

Occupation:


PARTNER INFORMATION (if the patient is pregnant, then “partner” is the father of the pregnancy)


First Name:

Last Name:

Date of Birth:

Occupation:


PATIENT CONTACT INFORMATION AND AUTHORIZATION


Cell:

Home:

Work:

May we leave a detailed voice message that includes confidential medical information and test results?

No

Yes



If we are unable to reach you, is there another person with whom we can leave a detailed voice message that includes confidential medical information and test results.

No

Yes



  • Patient has the right to revoke permission for the confidential voice mail
  • Patient assumes responsibility for information left on the confidential voice mail

REFERRING DOCTOR OR CLINIC INFORMATION

Name:

Phone:

Address:

City:


PREGNANCY AND EXPOSURE INFORMATION

Are you currently pregnant?

No

Yes

Due date:

Have you taken any medications during this pregnancy
(besides prenatal vitamins or Tylenol)?

No

Yes


Since becoming pregnant, have you had any

(Or if not pregnant please check current exposures)


Recreational Drugs:

No

Yes

Cigarettes:

No

Yes

Alcohol:

No

Yes

Fevers (greater than 101˚F):

No

Yes

X-rays (other than dental):

No

Yes

Do you have any of the following conditions?

 


Diabetes?:

No

Yes

A seizure disorder?:

No

Yes

Lupus?:

No

Yes

Are you adopted?

No

Yes

Is your partner adopted?

No

Yes


ALL OF THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE

PATIENT SIGNATURE:

DATE:

* = Input is required