Ob (Obstetrical) History Form
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1
2OB History Form
Patient Name ____________________________________________ D.O.B. ____________________________
New Pregnancy:
Weight before became pregnant ______________
Pregnancy Test taken:
Y / N
Date of Test __________________________
Menstrual History
First Day of Last Menstrual Period (LMP) _______________________ (approximate date) Normal/Abnormal
Age Periods Began: _________________________ How often ____________ Duration ___________________
Pregnancies (Include current pregnancy)
Total Number of Pregnancies: _______________
Number of Live Births: _________________
Number of Miscarriages: ___________________ (include mo/yr) Number of Abortions: __________________
Number of Children Living Now: __________________
Number of Premature Births <37 weeks) ________
:
Delivery Notes
Birth
Weight at
Baby’s
Weeks
Type of
Hospital
Physicians
Notes
Date
Birth
Sex M/F
Pregnant
Delivery
Where
Name
Vaginal or
Delivered
C- Section
1.
2.
3.
4.
Medical History
HISTORY
Yes/
DATE
COMMENT
HISTORY
Yes/
DATE
COMMENT
No
No
Allergic Rhinitis
Liver Disease
Anemia/Hematologic
Neurologic Disorder
Asthma/ Pulmonary
Renal Disease
Autoimmune Disorder
(Rh) Sensitized
Abnormal Pap Smear
Thyroid Disorder
Blood Transfusions
Trauma History
Breast Disorder
Uterine Abnormalities
Depression
Varicosities/DVT
Psychiatric Disorder
Anesthetic
Complications
Diabetes
Heart Disease
Hypertension/High Blood
Infertility or
Pressure
Other
Substance
Yes/No
Amt/Day
Amt/Day
# Years
Comments
Pre- Pregnancy
During
Used
Pregnancy
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Parent category: Medical