OB Risk Screening Questionnaire
Please complete ALL sections below!
Please check all that apply to your history
24411 Health Center Drive . Suite 200 C . Laguna Hills . CA 92653
1300 Avenida Vista Hermosa . Suite 150 . San Clemente . CA 92653
Office (949) 829-5500
  *Email:  
  *Full Name:   *Today's Date: (MM/DD/YYYY)  
  *Date of Birth: (MM/DD/YYYY)   *SSN: (XXX-XX-XXXX)  
  *Physician:   Patient Account #:  

GENERAL
    Yes No Will you be 35-38 years old when you deliver?
    Yes No Will you be 39 years old or older when you deliver?
    Yes No Will you be less than 18 years of age at delivery?
    Yes No Are you allergic to any medications? List:
    Yes No Have you ever had a baby with Rh disease or related problems? (not to be confused with RH Negative)
    Yes No Are you pregnant with triplets (or more)?
    Yes No Are you pregnant with twins?
    Yes No Have you had a child die at an early age? Age: Reason:

FAMILY/GENETIC HISTORY
    Yes No Does anyone in your family have cystic fibrosis? Baby's father's family? List:
    Yes No Does anyone in your family have down syndrome or other genetic abnormalities? Baby's father's family?
List:
    Yes No Does anyone in your family have a bleeding problem - Hemophilia? Baby's father's family?
List:
    Yes No Is anyone in your family considered "slow" or has an unexplained condition of mental retardation? Baby's father's family?
List:
    Yes No Does anyone in your family have autism? Baby's father's family?
    Yes No Does anyone in your family have Muscular Dystrophy? Baby's father's family?
    Yes No Does anyone in your family have Spinal Muscular Atrophy? Baby's father's family?
    Yes No Does anyone in your family have Phenylketonuria (PKU)? Baby's father's family?
    Yes No Does anyone in your family have a serious genetic problem not listed above?
Baby's father's family?
    Yes No Does anyone in your family have a neural tube defect? (ex. meningomyelocele open spine, or anencephaly)?
Baby's father's family?
    Yes No Does anyone in your family have Huntington's Chorea? Baby's father's family?
    Yes No Are you of Jewish or French Canadian Heritage? Which?
Is baby's father? Which?
    Yes No Are you of Mediterranean or Asian heritage? Which?
Is baby's father? Which?
    Yes No Do you have sickle cell anemia or thalassemia? Which?
Is baby's father? Which?
    Yes No Have you ever been pregnant with a baby which had significant birth defects or genetic abnormalities?
    Yes No Were you on prescription medications when you got pregnant? List:
    Yes No Have you had an X-Ray or radioactive medications since your last menstrual period? If so, shielded
    Yes No Have you been exposed to any harmful chemicals during the pregnancy? List:

PAST OBSTETRICAL/GYNECOLOGIC
    Yes No Have you ever been told you have an abnormally formed uterus?
    Yes No Have you ever lost a pregnancy between 15 to 25 weeks?
    Yes No Have you had three or more miscarriages?
    Yes No Have you ever been diagnosed as having an incompetent cervix or had a cerclage? If yes, which?
    Yes No Have you ever been told you have uterine fibroids?

INFECTION RISKS
    Yes No Have you ever been treated for sexually transmitted disease? (ex.HPV, Syphilis, Gonorrhea, Chlamydia)
Which?:
    Yes No Have you or your partner ever been diagnosed with genital herpes? If yes, who?
    Yes No Have you been treated for 3 or more urinary tract infections within a one year period? When?
    Yes No Have you ever been told you are HIV positive?
    Yes No Have you ever had Fifth Disease (Parvovirus) or been exposed to fifth disease since being pregnant?
    Yes No Did you receive a transfusion of blood prior to 1985?
    Yes No Have you ever been diagnosed with Hepatitis B?

MEDICAL
    Yes No Have you ever had cancer which is in remission? Type of cancer:
    Yes No Are you currently being treated for cancer?
    Yes No Have you ever been told you have high blood pressure while pregnant?
    Yes No Are you taking medication to control high blood pressure? List:
    Yes No Have you been told you have high blood pressure from kidney disease?
    Yes No Do you have asthma? If yes, list any medications:
    Yes No Have you been hospitalized for breathing problems not related to asthma?
    Yes No If your mother took DES, have you ever delivered a premature baby?
    Yes No Do you have a history of seizures?
    Yes No Are you taking medication to control your seizures? If yes, list medications
    Yes No Have you ever been diagnosed with kidney problems, such as a structural defect, or pyelonephritis?
    Yes No If yes, do you have hypertension or other problems?
    Yes No Have you ever been diagnosed with a thyroid disorder?
    Yes No Are you taking medication for a thyroid disorder? If yes, list medication
    Yes No Do you have diabetes? If yes, list any medications you take to control your diabetes
    Yes No Do you have diabetes with high blood pressure, or kidney problems?
    Yes No Have you ever been diagnosed with systemic lupus erythematosus?
    Yes No Have you ever taken medications for lupus or had complications from your lupus? List:
    Yes No Have you ever been diagnosed with mitral valve prolapse?
    Yes No Have you ever been told you have heart problems?
    Yes No Have you ever been told you have a tendency to form blood clots easily (Blood Factor)?
    Yes No Have you ever had a stroke or other neurologic problem?
    Yes No Have you ever been told you have a low platelet count?
    Yes No Have you ever been treated for anxiety or depression?
    Yes No Are you currently being treated for anxiety or depression? If yes, which one?
Medications:
    Yes No Have you ever been treated for blood clots in your legs or lungs?

OBSTETRICAL
    Yes No Have you ever had a delivery by cesarean section? Reason:
    Yes No If you had a previous cesarean section, do you plan on having another cesarean section?
    Yes No If you had a previous cesarean section, are you planning on a VBAC (vaginal birth after cesarean section)?
    Yes No Have you ever delivered an infant weighing 9 pounds or more?
    Yes No Have you ever delivered an infant weighing less than 5 pounds at full term?
    Yes No During any previous pregnancy, did you have placental abruption?
    Yes No With any previous pregnancy, did you experience hemorrhage after delivery?
    Yes No Have you ever delivered a stillborn child?
    Yes No Have you been hospitalized and treated for premature labor or delivered a premature baby (36 weeks or earlier)?
    Yes No Have you ever had surgery on your uterus (fibroid removal, septum removal, etc.)
    Yes No Have you ever had surgery on your cervix (conization, freezing, LEEP, etc.)?
    Yes No Have you ever had a tubal pregnancy (ectopic pregnancy)?

SOCIAL HABITS
    Yes No Do you currently drink alcohol? Quantity Frequency
    Yes No Do you have bulimia, anorexia or any other serious eating disorder? Please explain:
    Yes No Do you ever feel threatened by physical, emotional or verbal abuse? Please explain:
    Yes No Do you currently smoke cigarettes? Quantity Frequency
    Yes No Have you ever had a history of substance abuse?
    Yes No Are you currently using recreational drugs? If yes, list
    Yes No Have you used any over the counter medications since becoming pregnant? List:
ENTER SECURITY CODE: