Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Pregnancy & Obstetric History Form
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Number of Pregnancies (Gravida)
Number of Live Births (Para)
Miscarriages / Ectopic / Terminations
Prior Delivery Methods
Pregnancy Complications
Gestational Diabetes History
Additional details
Preeclampsia History
Last Menstrual Period
____ / ____ / ________
Current Contraceptive Method
Fertility Treatments Received
Blood Type & Rh Factor
- A positive
- A negative
- B positive
- B negative
- AB positive
- AB negative
- O positive
- O negative
- Not sure
Current Medications
| Medication | Dose | How often |
|---|---|---|
Additional Notes
Patient Signature
Date
Pregnancy & Obstetric History Form template from formisoft.com. formisoft.com/intake-templates/pregnancy-ob-history