Pregnancy Health History Form
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1This medical record is confidential and will not be released to anyone except as may be required by law.
St. Croix County DHHS-Public Health Dept.
Date______________________________
Reproductive Health
1752 Dorset Lane, New Richmond, WI 54017
Client #____________________________
715-246-8365
Fax 715-246-8298
PREGNANCY HEALTH HISTORY
Name _____________________________________________ Date of Birth _____/_____/________ Age __________
Last
First
M
Please circle if you are allergic to:
No Allergies
Penicillin
Iodine
Zithromax
Doxycycline
Sulfa
Metal
Rocephin
Tetracycline
Latex
Local anesthetic
Amoxicillin
Other_______________________
List medications, vitamins, over-the-counter drugs, and/or herbs you take:__________________________________________
REASON FOR YOUR VISIT –PREGNANCY TESTING:
Are you planning a pregnancy at this time?
Yes
No
If you are pregnant, will you feel?
Happy
Not sure
Sad
Worried
Other:__________________________
If you are pregnant, do you want information on: (circle)
Insurance/BadgerCare Plus
Nutrition (WIC)
Prenatal care
Parenting
Adoption
Abortion
If your pregnancy test is negative:
Do you want a method of birth control?
Yes
No
What kind? _________________________
Do you want emergency contraception/condoms? Yes
No
Do you want a physical exam?
Yes
No
Do you want preconceptional planning?
Yes
No
MENSTRUAL HISTORY
st
When was the 1
day of your last period: _______/_____/_______ Was it Normal?
Yes
No
Have you had sex since your last period?
Yes
No
When: __________________
Since your last period, have you had any of the following?: (circle all that apply)
breast tenderness
fatigue
increased urination
nausea or vomiting
pain in your lower abdomen
SEXUAL HISTORY
Age of first intercourse: _______
Have you had a new sex partner in the last 90 days?
Yes
No
Has your partner had a different sex partner in the last 90 days?
Yes
No
Don’t know
Circle if you have:
vaginal sex
oral sex
anal sex
sex with men
sex with women
sex with both
PREGNANCY
How many times have you been pregnant? ________
Dates when your pregnancy(ies) ended: _____________________________________________________
Have you ever had an ectopic (tubal) pregnancy?
Yes
No
Are you currently breastfeeding?
Yes
No
Do you plan to breastfeed?
Yes
No
REPRODUCTIVE LIFE PLAN
Do you hope to have any (more) children?
Yes
No
How many children do you hope to have? ________
How long do you plan to wait until you (next) become pregnant? _________________________________________
What do you plan to do until you are ready to get pregnant? _____________________________________________
:
CONTRACEPTION
Are you currently using a birth control method?
No
Yes, what kind: __________________________________
When did you last use birth control: ___________________________
SOCIAL HISTORY
Do you smoke?
No
Yes _____# per day.
Do you want to quit
No
Yes
Do you drink alcohol?
No
Yes
Do you use street drugs?
No
Yes
Does alcohol/drugs cause problems in your life and/or are others concerned?
No
Yes
Do you feel threatened or afraid of someone in your life?
No
Yes
Do you have any concerns about:
Date rape
Forced/unwanted sex
Physical abuse
Weight
Do you have a health care provider if you are pregnant?
No
Yes
If yes, name & clinic: ___________________________________________________________
Have you ever received medical care/medications for your mental health?
No
Yes
To the best of my knowledge, the above information is complete and accurate and I request a pregnancy test.
Revised 01/2015
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