These questions focus on factors that may adversely affect the current pregnancy. In case of patient self-administration, the patient should be asked to complete pages 4 and 5.
Space is available on the right for patient explanations and physician notes.
Surgery A history of surgery or blood transfusion suggests a greater chance of isoimmunization and consequent erythroblastosis fetalis. Also, the patient's prior response to analgesia and anesthesia may be helpful in case the patient needs to undergo a cesarean section. Medications Studies have found that women consume 4 to 11 drugs, on average, during pregnancy, of which 40 percent are consumed during the first trimester. Thus, most women will benefit from advice about the risks of taking prescription and over the counter medications during pregnancy. Some drugs with known teratogenic risks are gold, lithium, isotretinoin, folate antagonists, valproic acid, prednisone, warfarin, and oral diabetic agents.