PRENATAL INTERVIEW FORM

This information will be kept in our files for office use only. If you choose our doctors as your primary care

physicians, this information will become part of your child’s permanent record in our office.

Today’s Date _______________________ Estimated Delivery Date ________________________

NAME___________________________________________________________________________

            Father’s Last Name (please print) First Name Initial

________________________________________________________________________________________

            Mother’s Last Name (please print) First Name Initial

Where will baby be delivered? (HOSPITAL) ______________________ OB/GYN______________________

FAMILY HISTORY

Mother: Have you had breast surgery?                                               Yes ? No ?

              Did you take hormones or medicines during pregnancy?     Yes ? No ?

              (Explain) __________________________________________________________________________

              Did you drink alcohol or smoke during pregnancy?             Yes ? No ?

              Do you have any history of vaginal group B strep?                         Yes ? No ?

              (Explain) __________________________________________________________________________

              Do you or the father have any history of STD’s (gonorrhea, chlamydia, trichomoniasis)? Yes ?  No  ?

        (Explain)___________________________________________________________________________

              Do you intend to breast feed your baby?                             Yes ? No ?

              Do you have an infant car seat that meets current safety standards? Yes ? No  ?

Any history in baby’s close relatives (grandparent, sibling, aunt, uncle) of: (please check appropriate items)

___Interrupted Pregnancies ___HIV/AIDS             ___Birth Defects                 ___Kidney Disease  ___Substance Abuse

___Tuberculosis                ___Diabetes                             ___Chemotherapy                            ___Thyroid Disease ___Other

___Allergies                      ___High Cholesterol       ___Bleeding Tendencies               ___Liver Disease

___Convulsions/Epilepsy    ___High Blood Pressure ___Sudden/UnexpectedDeath  ___Mental or Emotional Problems

___Other Heart Disease       ___Early Heart Attacks        or fatality from illness        ___Cancer

Other Children? (Please list name, age and gender)________________________________________________

_________________________________________________________________________________________

Whom may we thank for referring you to our practice? _____________________________________________