Important COVID-19 Update: Waiting Room Unavailable & Office Hours Change
WomanCare Patients
Patient Medical History
(Required if Medicare Patient)
Are you allergic to latex? *

Family History

Diseases
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Any family history of Birth Defects? *
Any family history of Twins? *
Which side?

Social History

Illegal Drug Use? *
Cigarette Smoker? *
Former smoker? *
Caffeine *
Alcohol Use? *
Sexuality/Contraception *
Hysterectomy

Medications

Prenatal vitamins *

Pregnancy Information

(total number of pregnancies)
(total number of births)
(total number of miscarriages)
(total number of terminated pregnancies)
(first day of last menstrual cycle)

Diagnostic Studies

Past Pregnancies

OR