Have you been vaccinated for rubella? О Yes О No О I’m not sure Have you ever been diagnosed with anemia? О Yes О No Have you been in a hospital in another О Yes, country: О No country in the past six months? Are you currently taking any medication? О Yes, name: О No Dose: Did you take any medication in the six months О Yes, name: О No prior to this pregnancy? Dose: Medical history related to pregnancy and gynecology Have you been pregnant before? О Yes, number of deliveries: О No number of miscarriages: number of abortions: If so, have you experienced any of the О pelvic pain, О anemia, О high blood pressure, О None following? О pregnancy related diabetes, О premature (please check the relevant boxes) delivery, О induced labour, О vacuum extraction, О caesarean section, О post partum bleeding, О big baby, О baby was too small, О jaundiced baby (yellow skin), О mastitis (breast inflammation), О difficulty recovering physically after delivery, О difficulty recovering mentally after delivery, О Other issues: Have you ever had a pap smear (cervical test)? О Yes, year: О No О I didn’t require any follow up testing О I had follow up tests Have you or your partner ever been diagnosed О Yes, namely: О No with an STI (sexually transmitted infection)? Year: Were you exposed to di-ethylstilbestrol when О Yes О No your mother was pregnant? (if you were born О I’m not sure before 1977) Are you circumcised? О Yes О No Mental Health history Have you ever received treatment from a О Yes, year: О No psychologist or psychiatrist? Immediate cause: Have you ever suffered from burn out, О Yes, namely: О No (postpartum) depression, an anxiety disorder Year: or an eating disorder?
Have you been vaccinated for rubella? О Yes О I’m not sure О No Have you ever been diagnosed with anemia? О Yes О No Have you been in a hospital in another country in the past six months? О Yes, country: О No Are you currently taking any medication? О Yes, name: Dose: О No Did you take any medication in the six months prior to this pregnancy? О Yes, name: Dose: О No Medical history related to pregnancy and gynecology Have you been pregnant before? О Yes, number of deliveries: number of miscarriages: number of abortions: О No If so, have you experienced any of the following? (please check the relevant boxes) О pelvic pain, О anemia, О high blood pressure, О pregnancy related diabetes, О premature delivery, О induced labour, О vacuum extraction, О caesarean section, О post partum bleeding, О big baby, О baby was too small, О jaundiced baby (yellow skin), О mastitis (breast inflammation), О difficulty recovering physically after delivery, О difficulty recovering mentally after delivery, О Other issues: О None Have you ever had a pap smear (cervical test)? О Yes, year: О I didn’t require any follow up testing О I had follow up tests О No Have you or your partner ever been diagnosed with an STI (sexually transmitted infection)? О Yes, namely: Year: О No Were you exposed to di-ethylstilbestrol when your mother was pregnant? (if you were born before 1977) О Yes О I’m not sure О No Are you circumcised? О Yes О No Mental Health history Have you ever received treatment from a psychologist or psychiatrist? О Yes, year: Immediate cause: О No Have you ever suffered from burn out, (postpartum) depression, an anxiety disorder or an eating disorder? О Yes, namely: Year: О No
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