Prenatal Registration and Obstetrical Questionnaire

Name Home Address Rank Home Phone Age Work Address Occupation

Date
Work Phone Ethnic Origin Caucasian Hispanic Asian Black American Indian Indian European Other

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Sponsor s Rank Sponsor s Home Phone

Age

Occupation

Work Phone

Sponsor s Work Address

Ethnic Origin Caucasian Hispanic Asian Black American Indian Indian European Other

What !as the "irst da# o" #our last menstrual period$ %%%%%%%%%%%%%%% Was the period& NOR'A( or ABNOR'A($ Are #ou& CER)AIN or *NCER)AIN o" this date$ Ho! old !ere #ou !hen #ou had #our "irst period$ %%%%%%%%%%%%%%%%% Are #our periods normall#& RE+*(AR or IRRE+*(AR$ Ho! o"ten do #ou usuall# get #our period$ .or ho! long do #ou usuall# "lo!$ Pain or cramps !ith #our period$ /ES E,er# %%%%%%%%% da#s.or %%%%%%%%%%% da#s NO SO'E)I'ES.

%%%%%%Ho! man# times ha,e #ou 0een pregnant$ %%%%%%Ho! man# li,e 0irths$ %%%%%%Ho! man# miscarriages or a0ortions$ %%%%%%Ho! man# children are at home$ Descri0e the last "orm o" 0irth control #ou used 0e"ore pregnanc#1 and !hen #ou stopped itI" #ou used 0irth control pills in the past1 !hen did #ou stop taking them$ %%%%%%%%%%%%% Normal Weight %%%%%%%% Height %%%%%%%%

Weight 2ust 0e"ore pregnanc# %%%%%%%%

Please list all past pregnancies.

PRE+NANC/ N*'BER DA)E WEE3S PRE+NAN) 4A+INA( OR C5SEC)ION (EN+)H O. (ABOR ANES)HESIA HOSPI)A( SE6 O. BAB/ WEI+H) O. BAB/ CO'P(ICA)IONS

1 2 3 4 5 During this pregnancy, have you e perienced any o! the !ollo"ing#

/ES NO CONDI)ION NA*SEA OR 4O'I)IN+$ 4A+INA( B(EEDIN+$ PAIN.*( *RINA)ION$ ABDO'INA( PAIN$ .(*1 CO(D1 'EAS(ES1 CHIC3ENPO61 OR O)HER I((NESS$ P(EASE E6P(AIN AN/ 7/ES8 ANSWERS-

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65RA/S$ )A3EN AN/ 'EDICA)ION$ 9ASPIRIN1 AN)IBIO)ICS1 E)C-:

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During PR()*O+, pregnancies, did you e perience any o! the !ollo"ing#

/ES NO A S)I((BORN BAB/$ A BIR)H DE.EC) OR ABNOR'A(I)/$ IN.AN) DEA)H .O((OWIN+ DE(I4ER/$ A PRE'A)*RE BAB/$ A BAB/ WI)H A SERIO*S IN.EC)ION$ A BAB/ AD'I))ED )O )HE IN)ENSI4E CARE *NI)$ A BAB/ WI)H ;A*NDICE E6CESSI4E B(EEDIN+ 9HE'ORRHA+E: A.)ER DE(I4ER/$ HOSPI)A(I<A)ION BE.ORE (ABOR$ RHO+A' IN;EC)IONS AN/ O)HER *N*S*A( OCC*RRENCE$ CONDI)ION P(EASE E6P(AIN AN/ 7/ES8 ANSWERS-

Do you have a personal history o! any o! the !ollo"ing#

/ES NO CONDI)ION +ENERA( HEA()H OBESI)/ *NDERWEI+H) AN/ CHRONIC I((NESS 'EN)A( OR PH/SICA( (I'I)A)IONS POOR DEN)A( CONDI)ION HEAD CHRONIC HEADACHES 'I+RAINE HEADACHES CONC*SSION OR B(AC3O*)S EPI(EPS/ OR SEI<*RES )*'ORS E/ES WEAR +(ASSES OR CON)AC) (ENSES B(*RRED 4ISION POOR NI+H) 4ISION 'O4IN+ SPO)S OR B(IND SPO)S EARS EAR IN.EC)IONS HEARIN+ (OSS WEAR HEARIN+ AIDS R*P)*RED EAR DR*' NOSE BRO3EN NOSE SIN*S IN.EC)IONS .RE=*EN) NOSE B(EEDS NASA( SEP)A( DE.EC) NOSE S*R+ER/ )HROA) )ONSI((I)IS OR )ONSI((EC)O'/ ADENOIDEC)O'/ S)REP )HROA) P(EASE E6P(AIN AN/ 7/ES8 ANSWERS-

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(AR/N+I)IS 9(OSS O. 4OICE:

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Do you have a personal history o! any o! the !ollo"ing#

/ES NO NEC3 (/'PH NODE ABNOR'A(I)IES )H/ROID PROB(E'S OR S*R+ER/ IN;*R/ .RO' ACCIDEN) (I'I)A)ION O. 'O4E'EN) RESPIRA)OR/ (*N+ PROB(E'S )*BERC*(OSIS 9OR INH 'EDICA)ION: POSI)I4E PPD 9)*BERC*(OSIS )ES): PNE*'ONIA OR BRONCHI)IS AS)H'A PNE*'O)HORA6 9CO((APSED (*N+: CARDIAC 9HEAR): HEAR) DISEASE1 PROB(E'S1 OR IRRE+*(AR HEAR) RA)E H/PER)ENSION 9HI+H B(OOD PRESS*RE: H/PO)ENSION 9(OW B(OOD PRESS*RE: HEAR) '*R'*R +AS)ROIN)ES)INA( 9S)O'ACH: DIABE)ES *(CERS1 S)O'ACH PROB(E'S CO(I)IS1 IRRI)AB(E BOWE( S/NDRO'E CHRONIC DIARRHEA CHRONIC CONS)IPA)ION EA)IN+ DISORDER 9B*(I'IA1 ANORE6IA: HE'ORRHOIDS OR REC)A( PROB(E'S +A(( B(ADDER PROB(E'S 4E+E)ARIAN *RINAR/ B(ADDER IN.EC)IONS 9*)I S: 3IDNE/ IN.EC)ION 9P/E(ONEPHRI)IS: 3IDNE/ S)ONES B(ADDER OR 3IDNE/ S*R+ER/ (EA3IN+ O. *RINE 9INCON)INENCE: I4P S 9IN)RA4ENO*S P/E(O+RA': HE'A)O(O+/ B(EEDIN+ )ENDENCIES B(OOD C(O)S OR S)RO3E 4ARICOSE 4EINS SIC3(E CE(( DISEASE OR )RAI) ABNOR'A( B(OOD )/PE 9HE'O+(OBINOPA)H/: B(OOD )RANS.*SION (E*3E'IA ANE'IA 9(OW B(OOD CO*N) OR (OW IRON: HE'ORRHA+E 9E6CESSI4E B(OOD (OSS: POSI)I4E HI4 )ES) OR AIDS POSI)I4E AN)IBOD/ SCREEN CONDI)ION P(EASE E6P(AIN AN/ 7/ES8 ANSWERS-

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HEPA)I)IS

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Do you have a personal history o! any o! the !ollo"ing#

/ES NO CONDI)ION +/NECO(O+/ PROB(E'S WI)H BIR)H CON)RO( PI((S ABNOR'A( PAP S'EAR 9D/SP(ASIA OR CIN: CO(POSCOP/ 9'ICROSCOPIC E4A(*A)ION O. )HE CER4I6: CR/OS*R+ER/ 9.REE<IN+ O. )HE CER4I6: CONE BIOPS/ 9RE'O4A( O. PAR) O. )HE CER4I6: IN.ER)I(I)/ WOR35*P PAIN.*( IN)ERCO*RSE SE6*A( 'O(ES)A)ION1 AB*SE1 RAPE .IBROID )*'ORS O. )HE *)ER*S O4ARIAN C/S)S REC*RREN) 9.RE=*EN): 4A+INA( IN.EC)IONS SE6*A((/5)RANS'I))ED DISEASE 9S/PHI(IS1 +ONORRHEA1 CH(A'/DIA1 HERPES1 )RICHO'ONAS: PE(4IC IN.(A''A)OR/ DISEASE 9PID: +ENI)A( WAR)S 'ISCARRIA+E ABOR)IONS 9E(EC)I4E: )*BA( PRE+NANC/ (/'PHA)IC S/S)E' ABNOR'A( (/'PH NODES HOD+3IN S DISEASE ER/)HE'A NODOS*' '*SC*(OS3E(E)A( '*SC(E ACHES1 PAINS1 OR S)RAINS BRO3EN BONES OR IN;*R/ )O '*SC(ES OR BONES S3E(E)A( ABNOR'A(I)IES 9SCO(IOSIS: BIR)H DE.EC)S OR +ENE)IC DE.OR'I)IES PH/SICA( RES)RIC)IONS )O 'O4E'EN) E6CESSI4E '*SC(E ACHES OR S)RAINS CARPA( )*NNE( S/NDRO'E .RE=*EN)(/ SEE A CHIROPRAC)ER NE*ROPS/CHIA)RIC E'O)IONA( PROB(E'S PS/CHIA)RIC HOSPI)A(I<A)ION DEPRESSION OR AN6IE)/ CHI(DHOOD SE6*A( AB*SE 'ARI)A( PROB(E'S SEEIN+ A PS/CHIA)RIS)1 PS/CHO(O+IS) OR SOCIA( WOR3ER O)HER CONDI)IONS DO /O* S'O3E )OBACCO$ DO /O* DRIN3 A(COHO(IC BE4ERA+ES$ HA4E /O* E4ER *SED 'ARI;*ANA1 SPEED1 COCAINE1 HEROIN1 CRAC31 (SD1 ACID OR O)HER 'IND5A()ERIN+ DR*+S$ DO /O* EA) *N*S*A( S*BS)ANCES 9S)ARCH1 PAIN)1 C(A/:$ P(EASE E6P(AIN AN/ 7/ES8 ANSWERS-

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ARE /O* .RE=*EN)(/ E6POSED )O& (O*D NOISES$ CHE'ICA(S1 SO(4EN)S1 OR PAIN) .*'ES$ HI+H )E'PERA)*RES$ 'ERC*R/1 (EAD OR CAD'I*'$ WHO(E BOD/ 4IBRA)IONS 9(I3E A ;AC3HA''ER:$ RADIA)ION$ PRO(ON+ED S)ANDIN+$

ARE /O* A((ER+IC )O AN/ 'EDICA)IONS$ ARE /O* A((ER+IC )O AN/ .OODS$

(ist them-

(ist them-

.ave you had any o! the !ollo"ing childhood illnesses#

/ES NO CONDI)ION CHIC3ENPO6 94ARICE((A: 9OR WAS 4ACCINA)ED: 'EAS(ES 9R*BEO(A: 9OR WAS 4ACCINA)ED: RHE*'A)IC .E4ER SCAR(E) .E4ER '*'PS 9OR WAS 4ACCINA)ED: +ER'AN 'EAS(ES 9R*BE((A: 9OR WAS 4ACCINA)ED: .OR AN/ 7/ES8 ANSWERS1 E6P(AIN CIRC*'S)ANCES-

.ave you had any o! the !ollo"ing surgical procedures#

/ES NO +A((B(ADDER RE'O4A( APPENDI6 RE'O4A( BREAS) BIOPS/ BREAS) EN(AR+E'EN) OR RED*C)ION S*R+ER/ ORA( S*R+ER/ P(AS)IC S*R+ER/ )*BA( S*R+ER/ (APAROSCOP/ D > C 9DI(A)A)ION AND C*RE))A+E: AN/ O)HER S*R+ER/$ CONDI)ION P(EASE E6P(AIN WHEN AND AN/ O)HER I'POR)AN) .AC)S-

Does any %e%ber o! your i%%ediate !a%ily have any o! the !ollo"ing#
/ES NO CONDI)ION HEAR) DISEASE OR HEAR) A))AC3 HI+H B(OOD PRESS*RE 3IDNE/ OR B(ADDER DISEASE )*BERC*(OSIS DIABE)ES E'O)IONA( OR 'EN)A( DISORDER S)RO3E1 B(OOD C(O)S OR PH(EBI)IS B(OOD 4ARIA)IONS 9SIC3(E CE((1 )HA(ASSE'IA1 +?PD: BIR)H DE.EC)S1 DOWN S/NDRO'E1 NE*RA( )*BE DE.EC)S HE'OPHI(IA '*SC*(AR D/S)ROPH/ OR C/S)IC .IBROSIS H*N)IN+)ON CHOREA )A/5SACHS DISEASE P(EASE NO)E WHICH .A'I(/ 'E'BERS ARE A..EC)ED-

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)WINS OR '*()IP(E BIR)HS CANCER CHRONIC I((NESSES DR*+ AB*SE 'A;OR OPERA)IONS PRE+NANC/ CO'P(ICA)IONS DID /O*R 'O)HER )A3E AN/ HOR'ONES WHI(E CARR/IN+ /O*$

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P,12.O,O2*34 $((D, 3,,(,,5($6

6he purpose o! this assess%ent is to deter%ine i! you %ay need the assistance o! our social service sta!!. +pon revie", you %ay be re!erred to one o! our social "or7ers, "ho %ay "ish to %eet "ith you to discuss so%e o! your ans"ers or concerns.
I A+REE I DISA+REE I ' *NCER)AIN I A' HAPP/ ABO*) )HIS PRE+NANC/'/ (I4IN+ CONDI)IONS ARE SA)IS.AC)OR/I A' .A'I(IAR WI)H )HIS NEI+HBORHOOD AND )HE 'I(I)AR/ BASES IN )HE AREA'/ 'ARRIA+E IS A HAPP/ ONE'/ H*SBAND HAS NE4ER AB*SED 'E AND@OR )HE CHI(DRENWHEN '/ H*SBAND IS AWA/1 I A' O3 AND CAN 'ANA+E '/ (I.E WE((WHEN '/ H*SBAND IS AWA/1 I HA4E .RIENDS AND .A'I(/ )O HE(P 'EWHEN '/ H*SBAND IS AWA/ A) WOR31 I HA4E )RANSPOR)A)ION )O 'A3E '/ APPOIN)'EN)S AND +O SHOPPIN+I DO NOT .IND (I.E S)RESS.*( 'OS) O. )HE )I'EI A' RARE(/ DEPRESSED'OS) O. )HE )I'E WE HA4E ENO*+H 'ONE/ .OR .OOD AND E6PENSESI DON ) DEPEND ON '/ H*SBAND .OR E4ER/)HIN+'/ H*SBAND WI(( NO) BE DEP(O/ED WHEN '/ BAB/ IS D*EI DO NO) )A3E DR*+S OR DRIN3 A(COHO(IC BE4ERA+ES'/ CHI(DHOOD WAS A HAPP/ ONEI HA4E NE4ER BEEN PH/SICA((/ OR E'O)IONA((/ AB*SED IN '/ (I.EI SHO*(D BE AB(E )O A))END '/ PRENA)A( APPOIN)'EN)S WI)HO*) CHI(DCARE CON.(IC)SI SPEA3 AND *NDERS)AND EN+(ISH WE((I PRI'ARI(/ SPEA3& %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% (AN+*A+E WE DO NO) NEED .INANCIA( ASSIS)ANCE )O 'AIN)AIN O*R (I4ESS)A)E'EN)

CO''EN)S& P(EASE .EE( .REE )O E6PAND ON AN/ O. /O*R ANSWERS )O )HE ABO4E =*ES)IONS-

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3,,(,,5($6 O9 $+6R*6*O$34 ,636+,

6he purpose o! this assess%ent is to deter%ine i! you %ay need the assistance o! our dietician sta!!. Please ans"er the !ollo"ing :uestions and %a7e additional co%%ents belo".
/ES NO SO'E)I'ES I A' )A3IN+ '/ PRENA)A( 4I)A'IN E4ER/ DA/I S3IP 'EA(S OR RE+*(AR(/ +O (ON+ PERIODS WI)HO*) EA)IN+I HA4E A HIS)OR/ O. +ES)A)IONA( DIABE)ESI HA4E A HIS)OR/ O. ANE'IAI HA4E A HIS)OR/ O. EA)IN+ DISORDERS1 S*CH AS B*(I'IA OR ANORE6IA I HA4E A HIS)OR/ O. HI+H B(OOD PRESS*REI A' C*RREN)(/ HA4IN+ PROB(E'S WI)H NA*SEA AND 4O'I)IN+I A' C*RREN)(/ HA4IN+ PROB(E'S WI)H CONS)IPA)ION OR DIARRHEAI A' C*RREN)(/ HA4IN+ PROB(E'S WI)H (E+ CRA'PSI A' C*RREN)(/ HA4IN+ PROB(E'S WI)H HEAR)B*RNI A' C*RREN)(/ HA4IN+ PROB(E'S WI)H 'I(3 A((ER+/I A' C*RREN)(/ S'O3IN+ CI+ARE))ESI A' C*RREN)(/ A+E AB OR /O*N+ERI A' C*RREN)(/ CRA4IN+ NON5.OOD I)E'S S*CH AS C(A/ OR DIR)I A' C*RREN)(/ .O((OWIN+ A SPECIA( DIE)I A' C*RREN)(/ *NDERWEI+H)I A' C*RREN)(/ O4ERWEI+H)I A' HA4IN+ PROB(E'S WI)H NO) EA)IN+ ENO*+HI .EE( I NEED INDI4ID*A( N*)RI)IONA( CO*NSE(IN+P(EASE P(ACE A CHEC3 9: B/ )HE .OODS /O* EA) RE+*(AR(/ NON5.A) OR AC S3I' 'I(3 (OW5.A) 'I(3 WHO(E 'I(3 /O+*R) 9RE+-@.RO<EN: CO))A+E CHEESE CHEESE 7CREA'ES8 9ICE1 SO*R1 CHEESE1 WHIPPED .ISH CHIC3EN@)*R3E/ (EAN RED 'EA) E++S BEANS HA'B*R+ER HO) DO+S .RIED CHIC3EN .R*I) 4E+E)AB(ES +RAIN CEREA( S*+AR CEREA( WHI)E BREAD WHEA) BREAD BROWN RICE WHI)E RICE 'AR+ARINE 1A*P''AOSE SA(AD DRESSIN+ N*)S COO3IN+ OI( CHOCO(A)E .AS)@.RIED .OODS +RA4/1 SA*CES WA)ER ;*ICE SODA 3OO(AID DESSER)S CAND/ COO3IES PAS)RIES S)A)E'EN)

ADDI)IONA( CO''EN)S&

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