Patients of Nurse Midwives ONLY will now been seen at 207 Sparks Avenue, Suite 301 in Jeffersonville.
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