Patient Health History Form | Golden Oak Midwives

We're so excited you've joined Golden Oak Midwives! Please fill out and submit this form prior to your first visit.

Prenatal Health History Form

Patient Information

First Name

Today's Date

Last Name

Your Email

Brief History of Current Pregnancy

First Day of Last Period

Estimated Due Date

Please provide a brief history of your current pregnancy. * (Such as: Have you had any nausea / vomiting? Breast tenderness? Have you had any bleeding? Was this pregnancy planned Were you using birth control?)

If yes, where and with whom have you received care?

Obstetrical History

Please describe your past obstetrical history. Include outcomes of each pregnancy, birthdates, where you delivered, type of delivery (vaginal or Caesarean), use of anesthesia and any postpartum complications.

Do you have any experience breastfeeding? How long did you breastfeed? Do you plan to breastfeed? Please describe any expectation or complications from previous experiences.

Please describe your gynecological history. Include any history of abnormal pap smears or history of sexually transmitted infections.

Please describe your menstrual history. Are your periods regular/irregular? Do you have your period every month? How many days do your periods last?

Date of last Pap?

Result of last Pap?

Do you have a history of STI? If so, please describe.

Additional Information

Please describe your personal medical history. This includes any allergies, childhood illnesses, past medical conditions, or chronic illnesses (i.e. asthma, diabetes, hypertension).

Have you ever had surgery? If yes, please describe.

Do you take any medications? Please include prenatal vitamins and / or herbal supplements.

Are you allergic to any medications or food? If so, what is the reaction?

Please describe your lifestyle. Include pre-pregnancy weight, exercise habits, any dietary restrictions and alcohol and/or drug use.

Prepregnancy Weight?

Height?

Please tell us about your family medical history. Do any first degree relatives have major medical issues?

What is your race/ethnicity?

If yes to a history of domestic violence /sexual abuse, please describe if you are okay doing so.

Please describe your social support.

We require our patients to have the COVID-19 vaccination. Please enter the dates you received your vaccination shots.

Date(s) of Covid-19 Vaccines and Type

Date(s) of Covid Booster Vaccines and Type

History of Covid Positivity--# of times, dates, severity, etc.

Please provide any additional information regarding your health that may be relevant to your current pregnancy or for your midwives to know.

Thank you!