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Current Pregnancy Information
First name
Last name
Today's Date
Due Date
Current Pregnancy
Is the baby’s father aware of the pregnancy?
Yes
No
Unsure
Baby's sex
Female
Male
Unsure
Date prenatal care began for this pregnancy:
Complication of present pregnancy:
Nausea
Vomiting
Excessive Fatigue
Venereal disease
Headaches
Visual disturbance
Urinary infection
Constipation
Bleeding
Vaginal discharge
Anemia
Describe other complications during pregnancy and/or comment on the above-checked complications:
Have you had a previous pregnancy?
Yes
No
Character of previous pregnancies, deliveries, post-partum, gynecology complications:
Miscarriage
Stillborn
Abortion
Live birth(s)
Explanation of previous pregnancies, including any relevant dates:
Drugs taken during pregnancy:
Non-prescription
Amphetamines
Prescription
Barbiturates
Alcohol
Tobacco
Cocaine (crack)
Heroin
LSD
PCP
Marijuana
IV Drug Use
Methadone
Methamphetamine
Other
Explanation of drugs taken:
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