Obstetrical Patient Medical Information Check-In Sheet - Aoa Arizona
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1
2Obstetrical Patient
Medical Information
Check-in Sheet
Date Form Completed:________________
Name_____________________________________________________
Insurance___________________________________________________
Address___________________________________________________
Hospital for Delivery_____Chandler Regional Medical Center___________
City_________________________________Zip___________________
Pediatrician__________________________________________________
Home Phone________________Work Phone_____________________
Obstetrician_________________________Breast_____Bottle__________
Last Menstrual Period_________________________________________
Occupation________________________________________________
Patient’s Age________Date of Birth________________________ _____
Baby’s Father’s Name_________________________Age______________
Patient’s Marital Status__________________________________ _____
Occupation___________________Work Phone______________________
Patient’s Social Security Number_______________________________
Ethnicity: Patient________________
Father_____________________
Preferred Language: ________________________________________
MEDICAL HISTORY
Personal Health History
1. Are you allergic to any medications?______ If yes, please list: ________________________________________________________________________
2. Please mark any condition that you have or have had in the past:
Epilepsy
High Blood Pressure
Depression
Heart Disease
Recurrent Urinary Tract Infections
Hepatitis
Kidney Disease
Chicken Pox
Herpes
Headaches
Asthma
Migraine Headaches
Blood Disease
Diabetes
Bowel Disease
Thyroid Disorder
Arthritis or Lupus
3. Please describe any health problems or symptoms that you are having at this time: ________________________________________________________
______________________________________________________________________________________________
Surgeries
Cosmetic Surgeries? _____
Past Birth Control
No prior surgeries
If yes, please include below
Type
Year
Type
Years used
Exposures Affecting Health
1. Do you smoke cigarettes?______ If yes, how many pack per day________
2. Do you drink alcoholic beverages________If yes, how often____________
What type of drink(s)? __________________________________________
3. Please list any medications taken since your last period: _____________________________________________________________________________
____________________________________________________________________________________________________________________________
4. Please list any “recreational drugs” used since your last period: (i.e. cocaine, marijuana, etc.) ________________________________________________
5. Do you have a history of blood transfusion, intravenous drug use, multiple sexual partners or sexual exposure to a gay or bi-sexual male, exposure to an
intravenous drug user, or have any other reason to believe you may have been exposed to AIDS?______________________________________________
6. Please list any sources of chemical or radiation exposure that you encounter: ____________________________________________________________
____________________________________________________________________________________________________________________________
7. If you are on a restricted diet, please describe: ____________________________________________________________________________________
____________________________________________________________________________________________________________________________
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