High-Risk Labor and Delivery Patient Intake Questionnaire
Please complete this intake questionnaire to help our care team prepare for your high-risk labor and delivery. Your information will be kept confidential and used to provide the best possible care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Expected Delivery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Reason for High-Risk Status
*
Please Select
Pre-existing medical condition
Pregnancy complications
Multiple gestation (twins, triplets, etc.)
Advanced maternal age
History of preterm birth
Other
Brief Medical History (relevant conditions, surgeries, or complications)
Current Medications
Known Allergies
Primary Care Provider or OB-GYN Name
Submit Intake
Should be Empty: