Personal Medical History Template printable pdf download

Name: ____________________________________ Date of Birth: ____________ Today’s Date: ___________

Questions Regarding Your Current Pregnancy

What was the first day of your last menstrual period (LMP)? ____________________________________

Are your periods regular? Yes/No

How often do they occur? ________________________

Where you using contraception at the time you became pregnant? Yes/No

When was your last pap smear? ___________ What were the results? Normal/Abnormal

What kind of pregnancy test did you do? Urine/Blood

When was your first positive pregnancy test? _________________

Since your LMP, have you had any early pregnancy symptoms (nausea, vomiting, fatigue, breast tenderness,

etc)? Yes/No

If yes, please describe: ___________________________________________________________

___________________________________________________________________________________________

Have you had any vaginal bleeding? Yes/No

If yes, please describe: ________________________________

Have you had any problems with your prior pregnancies? Yes/No

If yes, please describe: _____________

___________________________________________________________________________________________

Since your LMP, have you used tobacco, alcohol or drugs? Yes/No

If yes, please describe: _____________

___________________________________________________________________________________________

Are you or the father of the baby of Jewish ancestry? Yes/No

Do you have cats in your home? Yes/No

Do you have contact with young children on a regular basis? Yes/No

Have you ever had chicken pox? Yes/No

If no, have you ever received the varicella vaccine? Yes/No

Have you ever been the victim of domestic violence? Yes/No

If yes, is the violence ongoing? Yes/No

Questions Regarding Genetic Risk/Teratology Counseling

(These questions pertain to you, the father of the baby’s and both of your families. If you answer yes to any

question, please provide details.)

Will you be older than 35 when the baby is due? Yes/No

Any history of thalassemia (more common in Italian, Greek, Mediterranean and Asians)? Yes/No

Any history of neural tube defects (spina bifida, anencephaly, etc)? Yes/No

Any history of congenital heart defects? Yes/No

Any history of Down Syndrome? Yes/No

Any history of Tay Sachs? (more common in Jewish and French Canadians) Yes/No

Any history of Canavan’s Disease? Yes/No

Any history of Sickle Cell Disease or trait? Yes/No

Any history of hemophilia or other blood disorders? Yes/No

Any history of Muscular Dystrophy? Yes/No

Any history of Cystic Fibrosis? Yes/No

Any history of Huntington’s Chorea? Yes/No

Any history of other chromosomal disorders not listed above? Yes/No

Any history of metabolic disorders not listed above (Type I DM, PKU, etc)? Yes/No

Do you or the father of the baby have any other children with any birth defects? Yes/No

Did either you or the father of the baby have any birth defects? Yes/No

Any history of women with 3 or more miscarriages? Yes/No

Have you taken any medications, other than prenatal vitamins, since your LMP (including vitamins, supplements,

OTC meds, etc)? Yes/No

Please list: ________________________________________________________

Any other genetic/environmental exposure not listed above? Yes/No

Personal Medical History Template

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