Pregnancy Questionnaire - Center for Fetal Medicine

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Center for Fetal Medicine and Women’s Ultrasound

6310 San Vicente Blvd. | Suite 520 | Los Angeles, CA 90047 Tel: 323-857-1982 | Fax: 323-857-5336

PATIENT INFORMATION & PREGNANCY QUESTIONNAIRE

Patient Information & Pregnancy Questionnaire

First Name

Last Name

Date of Birth (M/D/Y):

Address

City

State

Zip

County (CA only):

Occupation

PARTNER INFORMATION (if the patient is pregnant, then “partner” is the father of the pregnancy)

First Name:

Date of Birth (M/D/Y):

Occupation

PATIENT CONTACT INFORMATION AND AUTHORIZATION:

Cell :

Home :

Work

May we leave a detailed voice message that includes confidential medical information and test results?	Yes	No
If YES, check all that apply:	Cell	Home	Work
If we are unable to reach you, is there another person with whom we can leave a detailed voice message that includes confidential medical information and test results: If YES, complete below:

Name:

Relationship:

Number:

REFERRING DOCTOR OR CLINIC INFORMATION:

Name:

Phone:

Address:

City:

PREGNANCY AND EXPOSURE INFORMATION
Are you currently pregnant?	Yes	No

Due date:

Have you taken any medications during this pregnancy (besides prenatal vitamins or Tylenol)?	Yes	No
Are you currently pregnant?

Since becoming pregnant, have you had any: (Or if not pregnant please check current exposures) :

	Yes	No		Yes	No
Recreational Drugs			Diabetes
Cigarettes			A seizure disorder?
Alcohol			Lupus?
Fevers (greater than 101˚ F)			Are you adopted?
X-rays (other than dental)			Is your partner adopted?

ALL OF THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE

PATIENT SIGNATURE:

Date:

Patient Name:

Partner Signature:

Date:

Partner Name:

Genetic Counselor:

Phone:

Center for Fetal Medicine

Our Location

6310 San Vicente Blvd,
Suite 520
Los Angeles, CA 90048

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm

2001 Santa Monica Blvd,
Suite 870W
Santa Monica, CA 90404

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm