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Address Menstrual history Pregnancy history Surgical history Medical history Social history Contraception history Human Pregnancy Emergencies What is your name? _________________________ What is your date of birth? _________________________ Where and when were you born? _________________________ What is your gender? _________________________ Address What is your mailing address? ________________________ ________________________ ________________________ ________________________ Where are you located now? ________________________ What was your mailing address from birth until now? _________________________ _________________________ _________________________ _________________________ Where do you live now? _________________________ How long have you lived at this address? _________________________ What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency? _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ How long do you plan to live at this address? _________________________ Menstrual history What was the first day of your last menstrual period? (dd/mm/yy) Don’t know _________________________ Are you sure of that date? Yes No N/A _________________________ How many days does your period last? days _________________________ How many days are there between your periods? days _________________________ Are your periods regular? Yes No N/A _________________________ Pregnancy history How many times have you been pregnant in total (including this one)? _________________________ Deliveries
_________________________ Miscarriage, abortion, and ectopic
_________________________ Yes No If yes, please bring copy to your appointment _________________________ Have you had any pain during your current pregnancy? _________________________ Have you had any bleeding during your current pregnancy? _________________________ Have you had any nausea or vomiting during your current pregnancy? _________________________ Are you currently breastfeeding? _________________________ Surgical history Have you ever had any operations? _________________________ Yes No
_________________________ Yes No Have you or anyone in your immediate family ever had any problems with any anaesthetic? _________________________ Yes No N/A Medical history Do you use any prescription medicines? _________________________ Yes No If yes, please bring them with you _________________________ Do you use any other medicines such as herbal or homeopathic rememdies? If yes, please bring them with you _________________________ Yes No Do you have, or have you ever had any of the following: Asthma Yes No Other breathing problems Yes No High blood pressure Yes No Heart disease Yes No Heart valve problems Yes No Heart attack Yes No Stroke Yes No Migraine headaches Yes No Blood clots in your legs, arms or lungs (DVT) Yes No Bleeding disorder (like haemophilia) Yes No Clotting disorder (like Factor V Leiden) Yes No Anaemia Yes No Sickle cell disease Yes No Thalassaemia Yes No Seizures/fits/epilepsy Yes No Brain tumours Yes No Mental health problems Yes No Adrenal problems Yes No Liver problems Yes No Gallbladder problems Yes No Any other gastrointestinal problem Yes No (like ulcers or irritable bowel syndrome) Thyroid problems Yes No Do you have, or have you ever had, any of the following: Breast cancer Yes No Cancer of any kind Yes No What was the date of your last cervical smear? Abnormal cervical smear Yes No Treatment to your cervix (neck of the womb) Yes No Uterine fibroids Yes No Abnormally shaped uterus Yes No Pelvic infection Yes No Sexually transmitted infection Yes No Hepatitis Yes No Have you ever been told you are at Yes No increased risk of CJD or vCJD for public health purposes? Do you have any other medical problems not mentioned here? Yes No Social history Do you smoke tobacco? _________________________ Yes No Do you use any recreational drugs? _________________________ Yes No Contraception history Were you using any contraception at the time that you got pregnant with your current pregnancy? _________________________ If yes, what were you using? Do you have a copper coil (IUD) or Mirena coil (IUS) currently in place? _________________________ Yes No To the best of my knowledge, the information I have provided is correct and complete. Signature Date |
| What human pregnancy emergencies or complications need on-the-spot diagnosis and treatment? |
| Maliciously impregnated (medico-legal case that needs emergency contraception). |
| Spontaneous Vaginal Delivery |
| What symptoms, signs, and/or complaints indicate a human pregnancy emergency? |
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If you know any female of childbearing age maliciously impregnated, report an emergency (emergency contraception). Danger signs during pregnancy Call your physician if you experience any of the following symptoms during your pregnancy: Abdominal or epigastric pain Dizziness, blurred or double vision and spots before your eyes Fever over 101° and chills Hard, rigid abdomen with severe pain Noticeable decline in fetal movement Painful, difficult or scanty urination Persistent vomiting Sudden gush of fluid from the vagina Severe headaches Swelling around the eyes with accompanying swelling of the hands (some swelling in the legs and feet can be normal) Seizure(Convulsion) Vaginal bleeding |
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Questions you need to answer. Are you are female? _________________________ How old are you? _________________________ What is troubling you? _________________________ What is the date you are documenting these facts? _________________________ When was your last menstrual period? _________________________ How many live births have you given up to today? _________________________ How many still births have you given up to today? _________________________ How many miscarriages, abortions, dilatation and curettage have you gone through up to today? _________________________ Here are further details to answer this question. http://www.qureshiuniversity.org/abortion.html _________________________ What is the name, date of birth, mailing address, profile of those to whom you have given birth up to today? _________________________ How many biological children do you have up to today? _________________________ Do you have any adopted children? _________________________ What is the name, date of birth, mailing address, and profile of your adopted children? _________________________ What was your age you first became pregnant? _________________________ At what age did you first had first vaginal intercourse? _________________________ Did you ever have medical termination of pregnancy? _________________________ Who decided on medical termination of pregnancy? _________________________ Who terminated the pregnancy? _________________________ Who should decide medical termination of pregnancy? _________________________ Who should terminate the pregnancy? _________________________ What are other names for medical termination of human pregnancy? Induced abortion. Therapeutic abortion. Abortion is widely used among the general public. What is medical termination of pregnancy? Termination of pregnancy before 24 weeks of gestation prior to independent viability, using pharmacological, instrumentation, or surgical means, or after 24 weeks of gestation due to genuine reasons for medical termination of pregnancy. What are genuine reasons after 24 weeks of gestation for medical termination of human pregnancy? Maliciously impregnated. Criminal conspiracy. Rape. Incest. Continuation of the pregnancy is likely to result in the death or disability of the mother. Abnormalities of fetal growth. After birth, growth and development of the baby and community will be harmed. The woman is unable to give her consent. Is it a medicolegal case? _________________________ What type of abortion procedure is to be utilized? _________________________ What will be the effect of the abortion procedure on the woman? _________________________ What are the facts of fetal development at the time the proposed abortion is to be performed? _________________________ What are the reasonable alternative procedures? _________________________ Have you ever been pregnant in the past? _________________________ How important is it for you to avoid pregnancy now? _________________________ Very Somewhat Not at all How old were you when you first had vaginal intercourse? _________________________ ______years old. Are you planning to get pregnant in the next two years? _________________________ Have you had problems with previous pregnancies? _________________________ Please list the number of the following: _____ Pregnancies _____ Live births _____ Abortions _____ Miscarriages _____ Ectopic (tubal) pregnancies _____ # of C - secti ons How long ago was your last pregnancy? _________________________ _____ month(s), _____ year(s) Are you currently breastfeeding? _________________________ Have you had problems with previous pregnancies? _________________________ How do you plan to prevent pregnancy? _________________________ Have you ever been pregnant? _________________________ Have you been pregnant within the past year? _________________________ Age at first pregnancy: ________________ Number of times pregnant: __________ Number of live births: ______________ Number of living children: ___________ Ages: _____________ Number of C - sections: ____ _______ _ Number of miscarriages: ____________ Number of abortions: _______________ Number of ectopic/tubal pregnancies: ____________ Describe any complication you had during pregnancy (high blood pressure; depression; high blood sugars)___ ________________________________ Do you think you may be pregnant now? _________________________ How many pregnancies have you had? _________________________ How many total children have you given birth to up to now? _________________________ Any complications? _________________________ Any interrupted pregnancies? Yes No If yes, how many? _________________________ Have you had an hysterectomy? Yes No Date of Surgery? _________________________ Have you had your ovaries removed? Yes No Date of Surgery? _________________________ Are your ovaries intact? Yes No Date of Surgery? _________________________ Have you had tubal ligation? Yes No Date of Surgery? _________________________ Have you used birth control pills? Yes No How long? _________________________ During your pregnancy, how many ultrasounds did you have? One Two Three Four Five Six or more Miscarriage |
| Pregnancy Research and Studies |
| Normal Human Pregnancy |
| Human Pregnancy Emergencies |
| Pregnancy |
| Pregnancy emergency |
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When was your last menstrual period?
_________________________ What’s your due date or baby’s birthday? _________________________ |