Yes No

Family History

Diabetes Heart Disease Hypertension
(high blood pressure)		 Cancer *
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle

Yes
No


Yes
No


maternal side of family
paternal side of family

Social History


Yes
No


Yes
No

Yes
No

Coffee
Tea
Soda
N/A

Yes
No

NONE - patient is pregnant or trying to conceive
Abstinence
Oral Contraceptives (Birth control pills)
Depa-Provera injection
NuvaRing
Condoms
Withdraw
Vasectomy
IUD: Mirena or Paragard or Other
Tubal ligation
Hysterectomy Partial Complete

Medications


Yes
No

Pregnancy Information


Diagnostic Studies





Past Pregnancies



OR

Vaginal
C-Section
Natural
Epidural
Spinal

Boy
Girl