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Obstetrical History Form (For patients with a positive pregnancy test)
First day of last period: 20//
Expected date of delivery (if known): 20

Family Name: _______________________
Given Name(s): ______________________

Pregnancy History:#Delivery Date
Year / Month / Day

1Sex

Baby’s Birth
Weight_____ /_____ /_____

M/F

g

2

_____ /_____ /_____

M/F

g

3

_____ /_____ /_____

M/F

g

4

_____ /_____ /_____

M/Fg

Any pregnancy-related complications in the past:□High blood pressure □HELLP Syndrome □Seizures
Marital Status□Married Age at marriage: ____ years old□Divorced □Widowed □Remarried□Not marriedMarriage plans: □Yes □No
Other ()

Referral Letter □No□Yesunknown/

Fertility treatments: □No□Yes (Hospital name: _______________)□Timing method □Ovulation induction □AIH
□IVF (in vitro fertilization)□Fresh embryo transfer□Frozen embryo transfer (egg retrieval date://)□Pregnancy through egg donation

Past Pregnancies: ______times
Abortions: _______times
Weeks

or/Delivery: _______times
Stillbirths: _______times
Baby’sOutcome□Alive□Died□Alive□Died□Alive□Died□Alive□Died

Height: ________cm

Usual Weight: ________kg

Miscarriages: _______times (Ectopic Pregnancies: _______times)

Type of Delivery□Vaginal □Cesarean Section□Vacuum/Forceps□Vaginal □Cesarean Section□Vacuum/Forceps□Vaginal □Cesarean Section□Vacuum/Forceps□Vaginal □Cesarean Section□Vacuum/Forceps□Massive bleeding□Positive pregnancy test date: 20//
□Confirmed pregnancy at a hospital: 20//(Hospital name:or Aiiku Hospital)
Menstrual History
Cycle length: ~days Duration of bleeding:daysInterval: □Regular □Irregular
Menstrual flow: □Light □Moderate □Heavy
Menstrual complications: □No □Yes: _____________
Age at first period:
years old

□Placenta abnormalities

Inductionof Labor
□Yes
□No
□Yes
□No
□Yes
□No□Yes□No

NewbornComplications□Gestational Diabetes

Place ofDeliveryRemarks□Other:_____________________

Do you currently smoke?
□No □Secondhand smoke □Yes ( ______cigarettes/day)
Did you smoke before this pregnancy?
□No □Secondhand smoke □Yes ( ______cigarettes/day)
Do you currently drink alcohol?
□No □Socially □Almost everyday ( _______mL/day)

Family History
Diabetes: □No □Yes (who: ____________________)High blood pressure: □No □Yes (who: ___________)
Other (genetic, blood, etc.): ______________________

Place of Delivery □Aiiku Hospital (at Tamachi)□Other: ________________Cervical cancer checkup (Pap smear) within 1 year
□No
□Yes; result: □Normal □Abnormal□Not decided

Current medications: ___________________________Have you ever had any of the conditions/disorders listed below?
Past Medical History: □No □Yes

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Please give details (diagnosis, hospitalizations, surgeries, etc.)
about the items you checked in the left column.

□ Central nervous system (including cerebral vascular diseases – blood vessels in the brain)□ Respiratory disease (□Pneumonia □Bronchitis □Asthma – Last episode:years old)
□ Gastrointestinal disease (□Appendicitis)□ Liver disease (□Hepatitis)□ Kidney / Urological disease (□Nephritis □Pyelonephritis □Bladder inflammation)□ Blood disease (□Thalassemia)□ Heart disease (□Abnormal EKG □Arrhythmia)□ Thyroid disease (□Hyperthyroidism □Hypothyroidism □Chronic thyroiditis (Hashimoto Disease)□ Bone disease□ Muscle disease□ Uterine disease (□Uterine malformation □Uterine fibroids □Other)□ Disease of the ovaries and fallopian tubes (□Ovarian cyst □Blocked / fluid-filled fallopian tube)□ External injury / poisoning□ Blood group incompatibility□ Autoimmune disease□ Essential hypertension (idiopathic hypertension)□ Diabetes□ Psychiatric / Mental disorder (□Panic disorder □Bipolar disorder □Eating disorder □Other)□ OtherHave you had any of the following complications during pregnancy or delivery?
Obstetrical History: □No □Yes
□ Threatened miscarriage□ Shortened cervix□ Placental abruption□ Pregnancy-induced
hypertension□ Fetal growth restriction□ Sexually transmittedinfections□ Other□ Vaginal bleeding duringpregnancy□ Cervical laceration□ Cervical surgery (LEEP)□ Preeclampsia□ Placenta previa (low-lying)□ Gestational diabetesPlease give details about the items you checked in theleft column.

□ Preterm labor□ Incompetent cervix□ Cervical surgery (cone biopsy)□ Premature rupture of membranes(before 37 weeks)□ Pulmonary embolism (blood clotin the lung)□ Stillbirth

Aiiku Clinic International Unit
Revised 2017/10/20 PC desktop