Diabetes Hereditary Disease High Blood Pressure Malformations Twins/Triplets Mental Illness/Depression Other (include obstetrical or anesthetic) type: Medical History: Have you had any of the following: Yes No Yes No Asthma Autoimmune disease Blood Clots Bleeding/clotting disorder Heart High Blood Pressure Diabetes Thyroid Stomach/bowel problems Epilepsy Renal/urinary tract Hepatitis/liver disease HIV/AIDS Sexually Transmitted Infections Tuberculosis Chicken Pox/varicella Mental Illness Depression Anesthesia problems Blood transfusions Operations Other Illness: ___________________ Type: ____________________________ Are you taking prenatal vitamin? Were you taking folic acid prior to pregnancy? How many tobacco products do you use each day? How many alcoholic drinks have you had during this pregnancy? Have you used street drugs in this pregnancy? If yes, what type and how often? Do you have any spiritual beliefs that will affect your prenatal care? Would you like to know more about a Healthy Babies Program that offers support for prenatal vitamins, classes and healthy foods? you like to meet with a dietician?
Diabetes Hereditary Disease High Blood Pressure Malformations Twins/Triplets Mental Illness/Depression Other (include obstetrical or anesthetic) type: Medical History: Have you had any of the following: Yes No Yes No Asthma Autoimmune disease Blood Clots Bleeding/clotting disorder Heart High Blood Pressure Diabetes Thyroid Stomach/bowel problems Epilepsy Renal/urinary tract Hepatitis/liver disease HIV/AIDS Sexually Transmitted Infections Tuberculosis Chicken Pox/varicella Mental Illness Depression Anesthesia problems Blood transfusions Operations Other Illness: ___________________ Type: ____________________________ Are you taking prenatal vitamin? Were you taking folic acid prior to pregnancy? How many tobacco products do you use each day? How many alcoholic drinks have you had during this pregnancy? Have you used street drugs in this pregnancy? If yes, what type and how often? Do you have any spiritual beliefs that will affect your prenatal care? Would you like to know more about a Healthy Babies Program that offers support for prenatal vitamins, classes and healthy foods? you like to meet with a dietician?
Bonnyville%20OB%20Medical%20History.docx