New OB History Form

Joshua Johannson M.D., FACOG - Obstetrics and Gynecology
Patient's Name
DOB

MonthDayYear
Date
Date form Completed

MonthDayYear
Date
Last Menstrual Period
Name of Infant's Father
Phone Number
Format: (000) 000-0000.
Husband/Domestic Partner
Phone Number
Format: (000) 000-0000.
Pediatrician
Phone Number
Format: (000) 000-0000.
Genetic Screening and Infection History

Please check answer below, if no then move on. If yes then please check other and explain*
Patient’s age will be 35 years or older at estimated delivery date

Other
Thalassemia (Italian, Greek, Mediterranean, or Asian background: MCV < 80-

Other
Neural Tube Defect (Meningomyelocele, Spina Bifida, or Anencephaly)

Other
Congenital Heart Defect

Other
Down Syndrome

Other
Tay-Sachs (eg, Jewish, Cajun, French Canadian)

Other
Caravan disease

Other
Sickle Cell Disease or Trait (African)

Other
Hemophilia or other Blood Disorders

Other
Muscular Dystrophy

Other
Cystic Fibrosis

Other
Huntington's Chorea

Other
Mental Retardation

Other
Other Inherited Genetic or Chromosomal Disorder

Other
Maternal Metabolic Disorder (eg, Type 1 Diabetes, PKU)

Other
Patient or Baby’s Father had a child with birth defects not listed above

Other
Recurrent Pregnancy Loss, or a stillbirth

Other
Medications (including Supplements, Vitamins, Herbs, OTC Drugs) Illicit/ Recreational Drugs, Alcohol

Other
Any other Genetic History

Other
Live with someone with TB or exposed to TB

Other
Patient or Partner has history of Genital Herpes

Other
Rash or Viral Illness since last menstrual period

Other
History or STD, Gonorrhea, Chlamydia, HPV, Syphilis

Other
Other infection History

Other
If yes, was person tested for fragile X?
Have you ever had any of the following? Please check all that apply
C - Section: How many ______
Stillbirth: How many ___
Other delivery complications
Patient's Signature
Should be Empty: