International OB Questionnaire

Center for Women's Health

Obstetrics Questionnaire
Instructions
1. If unsure, use your best guess.
2. Input "idk" for any unknown answers.
3. If you have any questions, please email us at nurse@cfwhguam.com
4. Please "SUBMIT" form when complete. Do not leave page until receiving "Thank You" message.
* Required fields
Citizens and legal residents of the United States should complete our domestic questionnaire. Please click HERE for the correct form.
*

I am not a citizen or legal resident of the United States.
Today's Date

MonthDay Year
Age
Name*

Family Name Given Name
Date of Birth*

YearMonth Day
yyyy-mm-dd
Email*

Confirmation Email
Home Country*
Patient's English Language Proficiency*

NoneElementaryLimitedWorkingFluent
- None - patient has no working knowledge of English
- Basic / Elementary - patient has trouble communicating in English. Patient can only understand or speak few words.
- Limited working - able with difficulty to answer and ask questions during exams.
- Professional Working - able with little difficulty to answer and ask questions during exams
- Fluent - able with no difficulty to answer and ask questions during exam
Patient agrees an English speaker will accompany her to all exams and to the hospital.*
Patient agrees that she will have access to an English speaker while on island.*
When will patient arrive on Guam?*

YearMonth Day
yyyy-mm-dd
Will you be using an agent, representative or broker on Guam?*

YesNo
Broker/Agent Name*

First Name Last Name
Broker/Agent Phone*
Telephone on Guam (if known)
Address or Hotel on Guam (if known)
How will you pay?*

I have local Guam insurance.I will pay cash.
Current Pregnancy
Guam Memorial Hospital (GMH) is the only public hospital on Guam with an OB ward. Does patient plan to complete pregnancy on Guam and deliver at GMH?*

YesNo
First Day of Last Menstrual Period*

MonthDay Year
yyyy-mm-dd
LMP EDC*
Gestation
Guam Start Date
*

I agree my first appointment on Guam will be no later than the date listed above.
Has patient received prenatal care for current pregnancy?*

YesNo
Number of Visits*
First Appointment*

YearMonth Day
yyyy-mm-dd
Last Appointment*

YearMonth Day
yyyy-mm-dd
Number of Ultrasounds*

What laboratory tests have been completed for this pregnancy?*

NoneBlood TypeAntibody screeningComplete blood count (CBC)UrinalysisUrine CultureRepeat CBCGlucose screening test (1 hour)Glucose screening test (3 hour)Rh antibodiesGroup B streptococci (GBS)Genetic TestingCarrier screeningOther (list below)
Other laboratory tests?*
Prenatal records will be delivered to CFWH by*

email to nurse@cfwhguam.comfax to 1-877-797-7025mail to address below
Center for Women's Health

744 N Marine Corps Dr

Ste 121

Tamuning, GU 96913

USA
Obstetrics History
Total pregnancies including current*
Input Order: oldest to most recent
Pregnancy 1

Delivered SingleDelivered TwinsDelivered TripletsDelivered 4+MiscarriageElective AbortionEctopic Pregnancy

Complications*

NoneAbnormal placenta growthPlacenta previaBottom 10 percentile fetal growth for gestational ageRh sensitizationPreeclampsiaGestational diabetesFetal breech positionPreterm laborPostpartum issuesOther not listed

Pregnancy 2

Delivered SingleDelivered TwinsDelivered TripletsDelivered 4+MiscarriageElective AbortionEctopic Pregnancy

Complications*

NoneAbnormal placenta growthPlacenta previaBottom 10 percentile fetal growth for gestational ageRh sensitizationPreeclampsiaGestational diabetesFetal breech positionPreterm laborPostpartum issuesOther not listed

Pregnancy 3

Delivered SingleDelivered TwinsDelivered TripletsDelivered 4+MiscarriageElective AbortionEctopic Pregnancy

Complications*

NoneAbnormal placenta growthPlacenta previaBottom 10 percentile fetal growth for gestational ageRh sensitizationPreeclampsiaGestational diabetesFetal breech positionPreterm laborPostpartum issuesOther not listed

Pregnancy 4

Delivered SingleDelivered TwinsDelivered TripletsDelivered 4+MiscarriageElective AbortionEctopic Pregnancy

Complications*

NoneAbnormal placenta growthPlacenta previaBottom 10 percentile fetal growth for gestational ageRh sensitizationPreeclampsiaGestational diabetesFetal breech positionPreterm laborPostpartum issuesOther not listed

Pregnancy 5

Delivered SingleDelivered TwinsDelivered TripletsDelivered 4+MiscarriageElective AbortionEctopic Pregnancy

Complications*

NoneAbnormal placenta growthPlacenta previaBottom 10 percentile fetal growth for gestational ageRh sensitizationPreeclampsiaGestational diabetesFetal breech positionPreterm laborPostpartum issuesOther not listed

Have you ever had pregnancy induced...*

Gestational DiabetesAsthmaHypertension/High Blood PressureCardiomyopathyHyperthyroidismHypothyroidismOther not listedNone
Interested in Tubal Ligation (permanent sterilization through tubes tied)?*

YesNo
Medical History
Current Medications*

NoneIronPrenatal VitaminsOther
List Other Medications*
Weight/Height*
History of STI/STD?*

NoneSyphilisChlamydiaGonorrheaHIV/AIDSHepatitis BHepatitis COther (list below)
Ever diagnosed with the following?*

HyperthyroidismHypothyroidismCancerEpilepsyDiabetesAnxiety or DepressionBipolar DisorderAsthmaAnemiaHypertensionBlood DisorderKidney ProblemsEating DisorderTuberculosisZika virusSARS or MERSCovid-19None of the above
When was A1C level last checked?*
yyyy-mm
What was last A1C level?*
List other relevant diseases / illnesses / STI / STD
I have received the following vaccines:*

Diphtheria; Tetanus; Pertussis (DTaP or Tdap)Hepatitis BMeasles; Mumps and Rubella (MMR)PolioVaricella (Chickenpox)None of the above
Social History
Does patient use vaping or e-cigarette products?*

NeverCurrentFormer
Last Used*
year and month
Does patient use smoking tobacco - Cigarettes, Cigars, or Pipe?*

NeverCurrentFormer
Amount Per Day*
Years Used*
Last Used*
year and month
Does patient use Marijuana?*

Never usedCurrent recreational userFormer recreational userCurrent medicinal userFormer medicinal user
Years Used*
Last Used*
year and month
Does patient have history of Illegal Drug use?*

Never usedCurrent userFormer user
Last Used*
year and month
Marital Status*

MarriedLive with partnerDivorcedLegally SeparatedSingle
Does patient have any limitations we should know about?*

NonePhysicalReligiousOther
Describe Limitation*
Requested Accommodation*
Is there anything else you would like us to know?
Do not enter information in the fields below.

Center for Women's Health only.
CFWH Notes
Calculated Gestation
Should be Empty:

	Date (mm/yy)	Performed by	Problems	Estimated Due Date from Ultrasound
Ultrasound 1
Ultrasound 2
Ultrasound 3
Ultrasound 4

Center for Women's Health

Current Pregnancy

Obstetrics History

Input Order: oldest to most recent

Medical History

Social History

Do not enter information in the fields below.