Pregnancy Hypertension Intake Form
Use this form to share pregnancy details, blood pressure history, symptoms, medications, and other information relevant to hypertension during pregnancy.
Patient & Pregnancy Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
*
Phone
Email
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Estimated Gestational Age (Weeks/Days)
Estimated Due Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pregnancy Type
*
Singleton
Twins
Triplets or More
Unknown
Obstetric History Summary (if relevant)
Hypertension History & Current Status
History of chronic hypertension
*
Yes
No
Unsure
Hypertension in a prior pregnancy
*
Yes
No
Unsure
History of preeclampsia or gestational hypertension
Preeclampsia
Gestational hypertension
Both
Neither
Unsure
Current diagnosis status
*
Diagnosed before pregnancy
Diagnosed during this pregnancy
Not diagnosed
Unsure
Current systolic blood pressure or typical systolic range
When was high blood pressure first noticed?
Monitoring blood pressure at home
*
Yes
No
Sometimes
Unsure
Symptoms, Risk Factors & Medications
Current symptoms or warning signs
*
Headache
Vision changes
Swelling
Right upper abdominal pain
Shortness of breath
Nausea or vomiting
Decreased fetal movement
Other
If other, please describe symptoms
Relevant risk factors
Prior kidney disease
Diabetes
Autoimmune disease
Obesity
Multiple gestation
Family history of hypertension or preeclampsia
Other
If other, please describe risk factors
Current antihypertensive medication(s)
Medication dosage and frequency
Aspirin, supplements, or other pregnancy-related medications
Additional medication notes or concerns
Clinical Notes & Consent/Acknowledgment
Additional Notes
Provider or Clinic Name
Signature
*
Submit Intake
Submit Intake
Should be Empty: