New OB History Form

Joshua Johannson M.D., FACOG - Obstetrics and Gynecology
Patient's Name
DOB

MonthDayYear
Date
Date form Completed

MonthDayYear
Date
Last Menstrual Period
Name of Infant's Father
Phone Number
Husband/Domestic Partner
Phone Number
Pediatrician
Phone Number
Genetic Screening and Infection History

Please check answer below, if no then move on. If yes then please check other and explain*
Patient’s age will be 35 years or older at estimated delivery date

NoOther
Thalassemia (Italian, Greek, Mediterranean, or Asian background: MCV < 80-

NoOther
Neural Tube Defect (Meningomyelocele, Spina Bifida, or Anencephaly)

NoOther
Congenital Heart Defect

NoOther
Down Syndrome

NoOther
Tay-Sachs (eg, Jewish, Cajun, French Canadian)

NoOther
Caravan disease

NoOther
Sickle Cell Disease or Trait (African)

NoOther
Hemophilia or other Blood Disorders

NoOther
Muscular Dystrophy

NoOther
Cystic Fibrosis

NoOther
Huntington's Chorea

NoOther
Mental Retardation

NoOther
Other Inherited Genetic or Chromosomal Disorder

NoOther
Maternal Metabolic Disorder (eg, Type 1 Diabetes, PKU)

NoOther
Patient or Baby’s Father had a child with birth defects not listed above

NoOther
Recurrent Pregnancy Loss, or a stillbirth

NoOther
Medications (including Supplements, Vitamins, Herbs, OTC Drugs) Illicit/ Recreational Drugs, Alcohol

NoOther
Any other Genetic History

NoOther
Live with someone with TB or exposed to TB

NoOther
Patient or Partner has history of Genital Herpes

NoOther
Rash or Viral Illness since last menstrual period

NoOther
History or STD, Gonorrhea, Chlamydia, HPV, Syphilis

NoOther
Other infection History

NoOther
If yes, was person tested for fragile X?

YesNo
Have you ever had any of the following? Please check all that apply

Gestational DiabetesPreeclampsia/ToxemiaC - SectionPre - Term DeliveryStillbirth
C - Section: How many ______
Stillbirth: How many ___
Other delivery complications
Patient's Signature*

Clear
Should be Empty: