Preterm Birth Medical History Form
Please complete this form to provide your obstetric and pregnancy history related to preterm birth. Do not include sensitive identification or financial information.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Information (Phone or Email)
*
Current Pregnancy Status
*
Currently pregnant
Not currently pregnant
Not sure
Number of Prior Pregnancies (including current, if applicable)
*
Number of Prior Preterm Births (before 37 weeks)
*
Most Recent Preterm Birth Details
Known Risk Factors or Contributing Conditions
History of preterm birth
Multiple gestation (twins, triplets, etc.)
Short cervix
Uterine or cervical abnormalities
Infections during pregnancy
Chronic medical conditions (e.g., hypertension, diabetes)
Other
Prior Treatments or Interventions for Preterm Birth Prevention
Progesterone therapy
Cervical cerclage
Pessary
Bed rest/activity modification
Other
Current Medications or Supplements
Additional Notes (anything else relevant)
Submit
Should be Empty: