Maternl Pregnancy Information

Enter your Email adress to begin: What number is this pregnancy: Click Here to find your estimated Due Date ( EDD ) by using your Menstrual Cycle Enter Your EDD Here: Age at conception:? Current Age in years:? Who is your healthcare provider? Provider Title: Physician CNM NP/APRN Emergency Contact: Relative Friend Other Contact Phone: Full Term: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Pre Term: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20    Abortions/Miscarriages: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Living Children: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Have you had a Cesarean C-section(C/S)? Yes  : No If yes, why did you have a C/S? Baby too Big Breech(feet or "buttocks" first" Placenta Previa/bleeding Twins/Multiples Fetal Heart Rate Problem Other Fetal Reasons Infection Other(explain below) Your Medical History Gestational Diabetes? Yes No Pre Gestational Diabetes? Yes No Chronic Hypertension? Yes No Pre Eclampsia? Yes No Cardiac Disease? Yes No Asthma? Yes No Thyroid Disease? Yes No Blood Clotting Problems? Yes No Tuberculosis? Yes No Active Hepatitis B? Yes No Active Hepatitis C? Yes No Sexually Transmitted Infections? Yes No Abnormal Bleeding? Yes No Known Fetal Anomaly? Yes No Other Information /Explain (List all separated by 'comma'): Genetics, Birth Defects and Infection Questions Do you or the father of your baby have a history of: Thalassemia or Mediterranean Anemia ? Yes No Neural Tube Defect-Spina Bifidia? Yes No Congenital Heart Disease? Yes No Down Syndrome? Yes No Sickle Cell Disease or Carrier? Yes No Hemophilia? Yes No Muscular Dystropy? Yes No Cystic Fibrosis? Yes No Mental Retardation? Yes No Other Birth Defects? Yes No Smoke Tobacco? Yes No Routinely Drink Alcohol? Yes No Use of 'Street Drugs? Yes No Herpes Infections? Yes No Gonorhea? Yes No Chlamydia? Yes No Syphillis? Yes No HPV? Yes No HIV? Yes No Other Information: SUBMIT   RESET