Maternal Health History Intake Form

Address Relationship to You Number of Pregnancies (Gravida) Number of Births (Para) Number of Miscarriages/Abortions Number of Living Children Current Pregnancy - Weeks Gestation Estimated Due Date Do you have any of the following conditions? Diabetes High Blood Pressure Thyroid Disorders Heart Disease Epilepsy Other If other or additional, please specify List all known allergies (medication, food, etc.) List all current medications and dosages (including prenatal vitamins & supplements) List any major surgeries and year Any family history of genetic disorders, diabetes, hypertension, or other significant conditions? Do you smoke? Yes No Former Do you consume alcohol? Yes No Occasionally Any recreational drug use? Yes No Prefer not to say