Fillable PATIENT WORKSHEET Why did your Doctor refer you

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PATIENT WORKSHEET Why did your Doctor refer you

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Date:
Name: Date of birth:
Referring M.D.: SSN:
Why did your Doctor refer you today?
Please describe any health problem or symptoms that you are having at this time:
Due Date: First Day of Last Menstrual Period:
(Please circle if Dated by Ultrasound or Last Menstrual Period)
Have you ever had an Ultrasound at D.P.A. in a prior pregnancy (please state the year)?
Are you allergic to any medications?
Latex Allergies? Tape Allergies? Iodine/Shellfish Allergies?
PREGNANCY HISTORY: (Include miscarriages, terminations, and/or ectopic pregnancies)
Date
Month/Year
Gestational
Age
(Weeks)
Birth
Weight
Sex
M/
F
Type of
Delivery:
Vaginal/
C-Section
Preterm
Labor:
Yes/
No
Comments/ Complications
GYNECOLOGICAL HISTORY:
Date
Current Weight Height
of last Pap smear?
Have you ever had an Abnormal Pap Smear?
If yes, when?
Any Procedures on your Cervix? (
Biopsy, LEEP, CRYO Surgery, Colposcopy)
Any Uterine abnormality? Yes No
Any Infertility problems?
Is this pregnancy: IVF (Invitro Fertilization) IUI (Intrauterine Insemin
ation)
MEDICAL HISTORY:
Please mark any condition that you have been treated for in the past or are currently being treated for.
YES NO YES NO
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PATIENT WORKSHEET
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Fibroids? Yes No Bicornuate Uterus? Yes No
Have you ever had any kind of Surgery (Please state year(s) procedure was
performed
)?
Do you or any family member have a history of problems with anesthesia?
If yes, please explain:
PERSONAL HEALTH HISTORY
Do you have any religious objections to any form of medical treatment (refusal of blood transfusion)?
If yes, please explain:
FAMILY HISTORY & GENETIC SCREENING
Have you or has the father of the baby had a child born with a birth defect?
(Spina Bifida, Hole in the heart, Down
Syndrome, Cleft lip)
If yes, please describe:
Did you or the father of the baby have a birth defect? If yes, please describe:
Please describe any abnormalities that have occurred in children of your family or the father of the baby’s
family (Mental retardation, birth defects, deformities, or inherited diseases such as hemophilia, muscular
dystrophy, or cystic fibrosis). How is this child/person related to you?
Is the father of the baby over the age of 50? Yes No
Do you or does the father of the baby have a history of pregnancy loses (
miscarriages or stillbirths)?
GENETIC SCREENING: (
Includes patient, father of baby, or anyone in either family)
YES NO YES NO
1. patient’s age >35 years as of estimated date of delivery
7. Hemophilia or other Blood Disorders.
2. Thalassemia (Italian, Greek, Mediterranean, or Asian
background) MCV < 80
8. Muscular Dystrophy.
3. Neural Tube Defect (Meningomyelocele, Spina Bifida, or
Anencephaly)
9. Cystic Fibrosis
4. Congenital Heart Defect
10. Down Syndrome
5. Tay-Sachs (Jewish
, Cajun, French Canadian)
11. Mental Retardation/ Autism
6. Sickle Cell Disease or Trait (African)
12. Other Inherited Genetic or Chromosomal
Disorder
PATIENT WORKSHEET
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EXPOSURES AFFECTING HEALTH:
Do you smoke cigarettes? If yes, How much per day?
Do you drink alcoholic beverages now
or did you before you became pregnant? If yes, how often?
Have you had any X-rays or any chemical exposure (
harsh chemicals at work) since
pr
Please list any medications being taken in this pregnancy (even befo
re knowing you were pregnant)
Please list any illicit or recreational drugs used since pregnant.
(Marijuana, Cocaine)
Are you on a restricted diet?
If yes, please explain:
PSYCHOSOCIAL SCREENING:
Do you have any problems (job, transportation, etc.) that prevent you from keeping your health care
appointments?
FOR OFFICE USE ONLY:
G: P: PRETERM: SAB: TAB: LIVING:
Southwest Location: 5761 S. Ft. Apache • Las Vegas, Nevada 89148
Summerlin Location: 10105 Banburry Cross, #430 • Las Vegas, Nevada 89144
Green Valley Location: 3001 Horizon Ridge Parkway • Henderson, Nevada 89052
Phone: (702) 341-6610 • Fax: (702) 341-6961 • www.DesertPerinatalAssociates.com
egnant?
PATIENT WORKSHEET
3 of 3
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PATIENT WORKSHEET Why did your Doctor refer you

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Completed 1 December 2020

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