PREGNANCY INFORMATION SHEET

NAME: _DOB _ E-MAIL ADDRESS (NO mail.mil):

Address: PATIENT PHONE #

Sponsor/spouse’s name: Sponsors/spuose’s Phone #

EMERGENCY CONTACT (other than above) Phone# How related?

ARE YOU? Active Duty Dependent Daughter Married Single Divorced Widowed

ETHNIC BACKGROUND (Patient): Father of Baby: _

RELIGIOUS PREFERENCE OCCUPATION Highest Level of Education

Patient/Significant other deployed within the last 2 years? Yes No Where/When?

Currently Deployed: Yes No Where/When

Have you traveled outside the country in the last 6 months? Yes , No if yes, where?

Primary language? How do you learn best? Reading Listening Demonstration Pictures Do you have any learning Disabilities: Vision Problems Hearing Deficit Psychological Concerns None?

1st day of Last Menstrual Period / / (MM/DD/YY)

Are you sure of the first day of your last period? Yes No

Do you have regular periods? Yes No

Were you using birth control when you got pregnant? Yes No if yes, which type? If unknown last period, when was your 1st positive pregnancy test? _

Pregnancy & Delivery History

Total # of pregnancies, including this pregnancy? Living children Full term deliveries Preterm deliveries Miscarriages/ ectopic Elective terminations

In the table below, please list your pregnancies, including miscarriages/terminations

Date of Birth Weeks Length of labor Vaginal or cesarean

Epidural/Spinal/None Hospital name & state M/F WT COMPLICATIONS

Medications and Allergies Please list any medication allergies and reactions: Please list any food or latex allergies and reactions: Are you taking Prenatal Vitamins? YES / NO Please list all medications you are currently taking:

Do you feel safe at home? Yes / No Have you received an influenza vaccine this season? Yes / No Do you exercise regularly? Yes / No Have you ever received the HPV vaccine? YES / NO Are you willing to accept a blood transfusion in life threating emergencies? Yes / No

PATIENT Medical History

YES

NO

COMMENTS include medications if taken

for the condition

FAMILY HISTORY Do you, father of the baby, or anyone in either family with:

include who had the disorder

YES

NO

DIABETES DOWN SYNDROME HIGH BLOOD PRESSURE HEART DEFECT MAJOR ACCIDENT/TRAUMA NEURAL TUBE DEFECT (meningocele,

Spina bifida, or anencephaly)

NEURO/EPILEPSY/MIGRAINE TAY-SACHS THRYOID DISEASE MUSCULAR DYSTROPHY HEART DISEASE CYSTIC FIBROSIS MITRAL VALVE PROLAPSE HUNTINGTON’S CHOREA PRIOR BLOOD TRANSFUSION SICKLE CELL DISEASE OR TRAIT ASTHMA/LUNG DISEASE HEMOPHILIA DIGESTIVE DISORDERS OR COLITIS (Crohn’s or UC)

THALASSEMIA

HEPATITIS/LIVER DISEASE PATIENT OR BABY’S FATHER HAD A CHILD WITH BIRTH DEFECTS NOT LISTED

PRIOR ABNORMAL PAP OR CERVICAL PROCEDURE

OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDERS

UTERINE ABNORMALITIES Does anyone in your immediate family have: list who is affected

BREAST ABNORMALITIES DIABETES KIDNEY DISEASE/UTI/STONES HIGH BLOOD PRESSURE VARICOSITIES/PHLEBITIS MULTIPLES (Twins) AUTOIMMUNE DISORDERS BLOOD CLOTS (pulmonary, deep

arterial/venous embolism)

DEPRESSION, ANXIETY, OR OTHER PSYCHIATRIC ILLNESS

CANCER (breast, uterus, ovary, colon, pancreas, prostate)

DOMESTIC VIOLENCE/ABUSE Have you now or ever used the following? Include amount currently used

PRIOR SURGERIES & YEAR TOBACCO, E-CIGARETTES ANESTHESIA COMPLICATIONS ALCOHOL WILL YOU BE AGE 35 OR AT TIME OF DELIVERY

MARIJUANA

STILLBIRTH ALTERNATIVE STREET DRUGS TUBERCULOSIS OR TB EXPOSURE Do you live with cats? HAVE YOU OR YOUR PARTNER HAD: Genital herpes, chlamydia, gonorrhea, syphilis, HIV, hepatitis B or C (indicate which in the comments)

Additional comments:

NUTRITION 1. Would you like to attend a class about nutrition and diet? YES / NO 2. Have you ever had weight loss surgery? YES / NO 3. Have you ever had any kind of diabetes? YES / NO 4. Do you know how to eat properly during pregnancy? YES / NO 5. Do you eat more now than before pregnancy? YES / NO 6. Do you exercise regularly? YES / NO

SKIN INFECTION

1. Have you or anyone you live with ever had a “staph” or MRSA infection or colonization? YES / NO 2. Have you had a recent admission (last 30 days) to a hospital, rehab, or other medical facility? YES / NO 3. Do you have any open skin wounds or ulcers? YES / NO 4. Do you live in crowded conditions (dorm or barracks)? YES / NO 5. Do you have chronic dermatitis? YES / NO

Dear Patient,

Welcome to BJACH 08/GYN Clinic. We are here for military families and want your visits to be safe, comfortable and productive. Visits with your health care provider will give you the opportunity to have your questions answered, address your concerns and participate in further education about your

gynecological condition, pregnancy or postpartum period. You and your provider are encouraged to work together effectively to address your health concerns.

A new pregnancy impacts everyone in your family. Your other child(ren) should be involved in learning

more about your new baby. You may have reservations about leaving them with someone else when

you attend your appointments. Discuss with your health care provider about times when your child(ren)

can have the opportunity to listen to the baby's heartbeat.

There are times during your appointments when the presence of your other child(ren) may not be

appropriate. We ask that you not bring children to visits that may be painful or embarrassing to you .

These may include appointments at which you receive an injection, have a surgical procedure, or an

internal examination. If you are pregnant, further evaluation may be needed, such as having a Non­Stress Test (NST) or prolonged monitoring in Labor and Delivery. Since we cannot predict all situations,

we ask that you always bring another adult with you to care for your child(ren) if the unexpected happens.

Examples of situations when the presence of children is NOT recommended: • Gynecology Consults/Preoperative Consults• Colposcopy, Loop Electrosurgical Excision (LEEP) or other gynecological procedures

• IUD consultation/insertion• Receiving injections

• Postpartum checkups/Pap Smear Procedures• Any time you have a serious concern about your pregnancy and baby• Around the 36 th week of your pregnancy and thereafter

Per OB/GYN Clinic Policy, children are NOT ALLOWED during: • Initial OB Registration

• Non-Stress Testing

The BJACH's policy is that children under 12 years of age must be under adult supervision at all times.

The clinic staff cannot be responsible for watching child(ren) during your visit with your health care

provider. You may be asked to reschedule your appointment if another adult is not present to supervise

your child(ren) when appropriate.

Thank you for adhering to this policy.

By signing this form you acknowledge and agree to follow our policy about children in the 08/GYN Clinic

Signature ___________________ _ Date: ___________ _

MEDDAC Form 2 (04 Feb 04) All previous editions are obsolete. Fort Polk, La 71459-5110 For use of this form see OB GYN Forms SOP.

MEDICAL RECORD - CONSENT FORM CYSTIC FIBROSIS CARRIER TEST

I understand that I am being asked to decide whether or not to have the Cystic Fibrosis Carrier test. This test can identify someone who is a carrier of this disease. By signing below, I show that I have been told what this test can and cannot do and that my questions were answered to my satisfaction. By signing below I understand that: 1. This test can tell if I am a carrier of Cystic Fibrosis (CF), which means I have the gene but not the disease. 2. The risk of being a CF carrier depends on my race and ethnic background. For example: a. For European Caucasian, Ashkenazi Jew couples there is a: 1:25 chance that one parent is a carrier 1:625 chance that both partners are carriers b. For Hispanic American couples 1:46 chance that one parent is a carrier 1:2,116 chance that both partners are carriers c. For African American 1:65 chance that one parent is a carrier 1:4,225 chance that both partners are carriers d. For Asian American 1:80 chance that one parent is a carrier 1:8,100 chance that both parents are carriers 3. I am the one to decide whether or not I am tested. 4. The test is not perfect some carriers are missed by the test. 5. If I am a carrier, in order to have a better idea of my baby's chances of getting the disease, testing the baby's father will be needed. 6. If both parents are carriers, your baby has a 1:4 chance of having CF. In that case, I will have the chance or more testing to tell whether my baby has the disease. 7. Some parents may not wish to continue a pregnancy if they know their baby has CF. 8. Some individuals have not been able to get insurance because of the test results. I understand that my military health coverage will not be changed. 9. CF testing, like any DNA testing, can show that someone is not the real father. If the person who is thought to be the father has a negative test, but the baby turns out to have the disease after birth, then it would be suspected that the real father is someone else. Possibly, other unknown family information may be recovered. I have read and understand the information provided to me about Cystic Fibrosis and have had my questions answered to complete satisfaction. I (circle one) would or would not like to have the Cystic Fibrosis Carrier test Patient's Name:_________________________________ (Print) ______________________________________________ Date:______________________________________ (Signature) Witness: ______________________________________ ______________________________________________ Date:______________________________________ (Signature)

MEDDAC Form 4 (04 Feb 04) All previous editions are obsolete. FORT POLK, LA 71459-5110 For use of this form see OB/GYN SOP.

MEDICAL RECORD - CONSENT FORM MATERNAL SERUM ANALYTE TEST

I understand that I am being asked to decide whether or not to have the Maternal Serum Analyte Screen. The Maternal Serum Analyte Screen tests the mother's blood for substances made by the baby and the placenta. The amount of these substances in the blood, plus the maternal age are used to calculate the risk of certain problems with the baby including open neural tube defects, Down's syndrome (Trisomy 21) and Edwards syndrome (Trisomy 18). By signing below I show that I have been told what this test can and cannot do and that my questions were answered to my satisfaction. By signing below I understand that: 1. This is a screening test only: it DOES NOT provide a diagnosis; rather, it predicts the likelihood of a problem occurring. 2. The Maternal Serum Analyte Screen tests for an increased risk of a baby with certain birth defects such as open neural tube birth defects, Down's syndrome, Edward's syndrome, and other related birth defects. 3. The Maternal Serum Analyte Screen, is not 100% accurate and is often abnormal when, in fact, the developing baby does not have one of these birth defects. 4. Open neural tube defects are abnormalities of the spinal cord or brain and occur in l or 2 out of every 1000 births. Overall. if I have an abnormal result on the Maternal Serum Analyte Screen, my baby has only a 4-7% risk of open tube defects. 5. Babies with Down's syndrome have a distinct physical appearance, mental retardation, and are at risk for other birth defects. About I in 800 babies are born with Down's syndrome (Trisomy 21) and the risk increases with the age of the mother. Overall, in women with an abnormal test result, the baby has less than 3% risk of having Down's syndrome. 6. Babies with Edward's syndrome (Trisomy 18) have serious mental and physical disabilities. Only l out of 10 affected babies live past their first year. Only 1 in 8000 babies are born with Edward's syndrome and the risk increases with the age of the mother. 7. I am the one to decide whether or not I am tested. 8. As noted above, the test is not perfect. Some defects are missed and there are many abnormal Maternal Serum Analyte Screen results that turn out to have no association with birth defects. If there are abnormal results, I will need further testing to determine if anything is wrong with my baby. I have read and understand the information provided to me about the Maternal Serum Analyte Screen and have had my questions answered to complete satisfaction. I (circle one) would or would not like to have the Maternal Serum Analyte Screen. Patient's Name: ___________________________________________ (Print) __________________________________________________ Date:_______________________ (Signature) Witness Name: ___________________________________________ (Print) __________________________________________________ Date:_______________________ (Signature)