West End Women'S Healthcare Center Vanderbilt Nurse Midwifery Program Page 3
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1
2
3Do you smoke?
O NO
O YES
If yes, how many cigarettes per day?________________________
Any Alcohol use?
O NO
O YES
If yes, how many drinks per week? _________________________
Any recreational drug use?
O NO
O YES
If yes, how often and what type of drugs? ___________________
Patient and Family Medical History
Please check any of the following that relate to you or your family
O Multiple births (twins, triplets)
O Gastrointestinal problems
O Infertility & recurrent
O Immunological/Infectious
miscarriages
disease
O Cancer
O Breast Disease
O STD, HPV, or Group B Strep
O Operations/Accidents
O High Blood Pressure
O Urinary Tract Problems
O Phlebitis/varicosities
O Hematologic
O Heart Disease
O Endocrine/Metabolic
O Neurological
O History of sexual /physical
(Diabetes/Thyroid)
abuse/trauma
O Lung Disease
O GYN Problems (abnormal pap
O Psychiatric/Mental Illness
O Other____________________
smears)
Genetic Patient and Family History
Please check any of the following that relate to you, father of the baby and both families
O Patients age > 34 at delivery
O Other inherited or chromosomal disorder
O Thalessemia
O Other structural birth defect
O Neural Tube Defect
O Maternal metabolic/endocrine disorder (Diabetes, PKU)
O Congenital Heart Defect
O Pt or baby’s father had a child with a birth defect not listed above
O Down syndrome
O Recurrent pregnancy loss (>2) and/or still birth
O Tay Sachs
O Canavan Disease, Gauchers
O Hemophilia or other blood disorders
O Cystic Fibrosis
O Huntingtons Chorea
O Mental Retardation/Autism
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