Patient Demographic Form - St. Mary's Medical Center

Maternal-Fetal Medicine & Genetics CenterPatient Demographic FormPlease complete prior to your appointment - all information you provide is confidential and used only in our officeto assist in your care.Date: __________________________I Name ______________________________________________________Date of Birth: ____-____-____Maiden Name __________________ Marital Status (circle): M S D W Soc. Sec # ____-____-____Address: ______________________________________________________________________________Apt.# and/or Street City State ZipOccupation ____________________________________________________________________________Home Phone: (_____)-_____-_________ Best time to reach you at home: __________________________Work Phone: (_____)-_____-_________ Best time to reach you at work: __________________________Patient Employer: __________________________________ Employer’s Phone (_____)-_____-_______Employer’s Address ____________________________________________________________________Street____________________________________________________________________________________City State ZipIIIIISpouse/Partner’s Name: __________________________________________________________________Last First MiddleDate of Birth: ____-_____-_____Soc. Sec. #: ______-_____-_____Occupation: __________________________________________________________________________Spouse/Partner’s Employer: ________________________Employer’s Phone: (____)______-_________Employer’s Address: ____________________________________________________________________Street____________________________________________________________________________________City State ZipNext of Kin (other than spouse/partner)Name __________________________________________Relationship to patient: __________________Home Address: ________________________________________________________________________Apt.# and/or Street City State ZipHome Phone: (____)_____-_________ Work Phone: (_____) ______-___________Referring Doctor/Clinic: __________________________________Phone: (_____)_______-__________Address: ______________________________________________________________________________Suite# and/or Street City State ZipIV Who referred you to this office? Your doctor __________ yourself________ other __________Why were you referred to this office? ______________________________________________________7994-15 pg. 1 Rev. 03/10

Personal InformationName you prefer to be calledAge nowAge at due date (patient only)Ethnic background/RaceBirthplaceReligious AffiliationEducation (highest degreeobtained: H.S., college, master’s etc.)PatientSpouse/PartnerVI This pregnancyFirst day of last period ________________ Ultrasound date ______________ due date ________________Please describe any complications in this pregnancy: __________________________________________How many times have you been pregnant? (include this one): ____________________________________Did you take oral contraceptives/hormones within 2 months of this pregnancy? (circle one) Yes or NoPlease describe any fertility treatment in this pregnancy: ________________________________________Do you smoke? (circle one) Yes or No - If yes, how many cigarettes in a day?____How many years? __Have you cut down or quit smoking since finding out you were pregnant? (circle one) Yes or NoDo you drink alcohol? (circle one) Yes or No - If yes, what do your drink? ________________________How many drinks per week before this pregnancy? ______________________________________How many per week since finding out you were pregnant? __________________________________Please describe chronic medical problems you have (e.g., diabetes, hypertension, etc.) ________________Please list any medications you have taken, prescribed or over-the-counter ________________________________________________________________________________________________________________Pain Assessment Scale 0 - 10 (0 being no pain – 10 in extreme pain)VII Your Past Pregnancy History:A. Please use the back of this page if you need more room for the following questions:For each of your pregnancy living or deceasedPre-term (20-36 wks) or fullBirth date Birth weight term (37-40 wks) at delivery? AliveFull Name (circle sex) mm/dd/yy lbs/oz circle one DeceasedM or F pre-term full termM or F pre-term full termM or F pre-term full termM or F pre-term full termM or F pre-term full termB. For any pregnancy loss: miscarriage (mis), still birth (SB), or elective abortion (EAb):Type of loss (circle one) Month/year How far along? Cause of loss if knownmis SB EAbmis SB EAbmis SB EAbmis SB EAbVIII Spouse ChildrenFor each of your spouses children living or deceasedFull Name Date of birth Birth wt. lbs/oz Alive/Deceased Cause of deathM or FM or FM or F7994-15 pg. 2 Rev. 03/10

IX.Family HistoryHave you or a family member ever seen a genetic counselor or had an amniocentesis performed?(circle one) Yes or No If yes, who & what was the reason?_______________________________________________________________________________________Do you know of any member of your family or your partner’s family who has any of the following?(Think of your children, grandchildren, parents, grandparents, aunts, uncles, cousins, nieces, or nephews,brothers and sisters and half brothers and sister)your his describe relationship to person affectedside side and what they haveNeural Tube Defectlike Spina Bifida or AnencephalyCongenital Heart Defect or MurmurFacial Abnormality like Cleft Lip or Palateother birth defectsBleeding problems like HemophiliaMuscular disorder like Muscular DystrophyNeurologic disorder like Huntington DiseaseOther inherited conditionlike Cystic Fibrosis or Sickle Cell AnemiaChromosomal disorder like Down SyndromeMental retardation with no known causeMore than 2 pregnancy lossesor any unexplained infant deathany other condition which concerns youFragile X SyndromeInherited ConditionsSome inherited conditions are more common in certain populations around the world. If you or your partnerare a member of certain ethnic groups, additional information is available regarding these conditions.(circle one)Are you or your partner of Ashkenazi (Eastern European) Jewish descent?Yes or NoHave you ever been tested for Tay-Sachs carrier status?Yes or NoAre you or your partner of Asian or Mediterranean descent?Yes or NoHave you ever been tested for thalassemia carrier status?Yes or NoAre you or your partner of African descent?Yes or NoHave you ever been tested for sickle cell carrier status?Yes or NoAre you and the baby’s father related in any way?Yes or No____________________________________________ _______________ ________________Nurse Review Date Time7994-15 pg. 3 Rev. 03/10