Tara A. Dullye, M.D., F.A.C.O.G. Obstetrical Questionnaire   Last Name: _________________________________________  Date:________________________ First Name:_________________________________________   Race:________________________ Date of Birth: _______________________   Age: _______ Marital Status:    Mar    Sing    Div    Wid    Sep Occupation: ____________________________________ Currently employed?   Yes    No Partner's Occupation: __________________________________________________________ If you are not currently married, please provide the father of the baby's demographics: Last Name: ___________________________   First Name: ______________________________ Address: _______________________________________________________________________ City: ________________________________________ State:________   Zip: ____________ Phone Number: _____________________ How many times, including this pregnancy, have you been pregnant? ____________ How many pregnancies did you carry until at least 37 weeks? ____________ How many miscarriages have you had? ____________ How many ectopic pregnancies have you had? ___________ Number of pregnancies in which you delivered multiple babies (twins, triplets, etc.)? ______ Number of living children you have? _________ Date of the first day of your last normal menstrual period? ____________________ How sure are you of the above-mentioned date?  Definite within a few days    Unsure Number of days typically between the first day of your menstrual periods (count from the            first day of one to the first day of the next)? _____________ How old were you when you first began having menstrual periods? ____________ Were you using any type of contraception when you conceived?   Yes    No If yes, what type? ______________________________________________________   Medical History Do you currently have or have ever had any of the following? Diabetes                                        Yes     No High Blood Pressure                       Yes      No Heart Disease                                 Yes      No Depression                                     Yes     No Postpartum Depression                   Yes     No Hepatitis                                        Yes     No Liver Disease                                  Yes     No Varicose Veins                               Yes     No Blood Clots in Veins or Arteries       Yes     No Thyroid Problems (high or low)         Yes     No Trauma                                          Yes     No Physical Abuse                              Yes     No Sexual Abuse                                Yes     No Prior Blood Transfusion                   Yes     No Asthma                                         Yes     No Tuberculosis                                  Yes     No Seasonal Allergies                         Yes     No Latex Allergy                                 Yes     No Breast Problems or Surgery            Yes     No Anesthetic Complications               Yes     No Abnormal Pap Smears                   Yes     No Uterine Abnormalities                     Yes     No Infertility                                        Yes     No Autoimmune Disorders (ex., lupus, rheumatoid arthritis, etc.)                      Yes      No Prior Gynecological Surgery (ex., cervix, uterus, ovaries or fallopian tubes)   Yes     No Kidney disease or frequent bladder infections                                              Yes     No Epilepsy or other neurological problems                                                      Yes     No Psychiatric Problems (ex., bipolar disorder, schizophrenia, etc.)                   Yes     No Other (if yes, specify):______________________________________________________   List any known drug allergies that you have: Drug Allergy Reaction                     List any medications that you are currently taking: Current Medications Dosage Reason Taking                                     List any surgeries that you have had: Date Surgery Type Anesthesia                               Describe any illnesses for which you are currently being treated: Illness Treating Physician/Telephone No.                       Do you currently smoke cigarettes?     Yes     No If yes, how many packs per day? ______     How many years? _______ Have you ever smoked cigarettes?      Yes     No If yes, how many packs per day?  ______      How many years? How long ago did you stop?  _________________________ Do you drink alcoholic beverages?    Yes      No If yes, what and how much do you drink per week? __________________________________ Did you drink alcoholic beverages prior to pregnancy?    Yes    No If yes, what and how much did you drink per week? __________________________________ Do you use illicit drugs such as cocaine, marijuana, amphetamines, etc.?     Yes      No If yes, what and how much? _____________________________________________________ Have you ever used any illicit drugs?     Yes      No If yes, how long ago? _____________________________________________________ If yes, what have you used? ___________________________________________________ Is a blood transfusion acceptable in a life-threatening emergency?      Yes     No Are you allergic to Latex?         Yes        No Genetic History Your age at the due date of this baby: ______ Father of the baby's age at the due date of this baby: ______ Do you or the baby's father or anyone else in either family have:     Thalassemia  Yes  No Italian, Greek, Mediterranean, or Asian background  Yes  No Spina biffida or anencephaly (missing brain)  Yes  No Heart defects (since birth)  Yes  No Down Syndrome  Yes  No Tay-Sachs  Yes  No Jewish, Cajun, or French Canadian background  Yes  No Canavan disease  Yes  No Sickle Cell disease or trait  Yes  No African background  Yes  No Hemophilia or other blood disorders  Yes  No Muscular dystrophy  Yes  No Cystic Fibrosis  Yes  No Huntington's Chorea  Yes  No Mental Retardation  Yes  No Autism  Yes  No Fragile X disease  Yes  No Other inherited genetic or chromosomal disorder  Yes  No Any birth defects not listed above  Yes  No If you answered yes to other inherited genetic or chromosomal disorder or birth defects, what type? ___________________________________________________________   Do you have any history of Diabetes or PKU?   Yes    No Have you ever delivered a stillborn baby?           Yes    No Have you had three or more miscarriages?        Yes   No What medications (including supplements, vitamins, herbs or over-the-counter drugs) have you taken during this pregnancy? _______________________________________________________________ __________________________________________________________________________________ Have you used any alcohol or drugs since your last menstrual period?   Yes   No If yes, what and how much? __________________________________________________________ Infection History Have you ever been exposed to tuberculosis?   Yes     No Do either you or your partner have genital herpes?   Yes     No Have you had a rash or any viral illness since your last period?   Yes     No Have you ever had Gonorrhea?   Yes     No Have you ever had Chlamydia?   Yes     No Have you ever had HPV (human papilloma virus)?   Yes     No Have you ever had Syphilis?   Yes     No Have you ever had any other sexually transmitted disease?   Yes     No Have you ever been diagnosed with H.I.V.?   Yes     No Have you ever had the Chicken Pox?   Yes     No Have you ever received the Chicken Pox Vaccine:   Yes     No Do you have or are you exposed to cats?   Yes     No If yes, has your cat been tested for toxoplasmosis?   Yes     No Do you routinely have contact with any toxic vapors, chemicals, or drugs?   Yes     No If yes, what kind and how much? ____________________________________________

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