Kaiser Prenatal Questionnaire Form – Fill Out and Use This PDF

PROVIDER / DATE:

MR #

PRENATAL QUESTIONNAIRE

NAME

PATIENT’S NAME (LAST, FIRST, MIDDLE)

ADDRESS

PREVIOUS NAMES

CITY, STATE AND ZIP CODE

IMPRINT AREA

DAY PHONE

EVENING PHONE

MESSAGE PHONE

RACE

RELIGIOUS PREFERENCE

LANGUAGE PREFERENCE

AGE

DATE OF BIRTH

OCCUPATION

EMPLOYER AND CITY

LAST GRADE COMPLETED

MARITAL STATUS

WHAT IS YOUR LIVING SITUATION?

■ Alone

■ With baby’s father

■ M

■ S

■ DP

■ Sep

■ D

■ W

■ Parents

■ Relatives

■ Friends

■ Domestic Partner/Partner

FATHER OF BABY / DOMESTIC PARTNER / PARTNER

NAME

ADDRESS IF DIFFERENT FROM ABOVE

DAY PHONE

EVENING PHONE

AGE

RACE

OCCUPATION

DOES FATHER OF BABY / DOMESTIC PARTNER / PARTNER HAVE ANY MEDICAL PROBLEMS /

CURRENTLY INVOLVED WITH BABY’S FATHER?

IN CASE OF EMERGENCY CONTACT:

IF YES, DESCRIBE:

■ Yes ■ No

■ N/A

YOUR LAST MENSTRUAL PERIOD

PREVIOUS PREGNANCIES CONTINUED

1. Date of the first day of your last period

Have any of your pregnancies involved:

6. A baby weighing less than 5 lbs 8 oz?

■ Yes

■ No

Was it a normal period?

■ Yes

■ No

7. A baby weighing more than 9 lbs?

■ Yes

■ No

Did it occur at the right time?

■ Yes

■ No

8. Premature labor? (before 8th mo.)

■ Yes

■ No

2. How many days apart are your periods?

9. Cesarean section?

■ Yes

■ No

3. What did you last use for birth control?

Provider Comments:

■ Depo provera

■ Norplant

■ Birth control pills

■ Diaphragm

■ Condom / spermicide

■ IUD

■ None

■ Other:

When did you stop using it?

PREGNANCY RISK FACTORS

......................4. Did you have a pregnancy test?

■ Yes

■ No

Since the pregnancy began have you?

If yes, what kind?

■ Urine

■ Blood DATE:

1. Had vaginal bleeding that required a visit

to the Emergency Department?

■ Yes

■ No

PREVIOUS PREGNANCIES

How many:

2. Had any severe nausea and vomiting that

1. Pregnancies have you had?

required a visit to the Emergency Department?

■ Yes

■ No

(Including current pregnancy)

3. Had a fever higher than 100 degrees?

■ Yes

■ No

2. Deliveries have you had?

4. Smoked cigarettes in the last 3 months?

■ Yes

■ No

3. Miscarriages have you had?

If yes, about how many per week do you smoke?

4. Abortions have you had?

5. Had any alcoholic beverages?

■ Yes

■ No

6. Taken any medications or drugs?

■ Yes

■ No

5. Living children do you have?

If yes, LIST:

YEAR

WHERE

LENGTH OF

HOURS OF

TYPE OF

TYPE OF

SEX

WT

COMPLICATIONS

PREGNANCY

LABOR

ANESTHESIA

DELIVERY