Patient Information
Questions
Check all the symptoms you have experienced in the last year and describe the details. Please specify if you are experiencing these now or in the past.
If you are unsure, select the 1st of the month for the beginning, the 15th for the middle of the month and the 30th for the end of the month. (Some tests require an exact date, so it may be required to keep track of your cycles.)<br/>
(How many days between periods? 28 days? 30 days? etc.)
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When is the baby due?
Please put N/A if you are not pregnant.
Total number of times you have been pregnant
Number of Living Babies you have Delivered
Number of miscarriages that you have had (including stillbirths)
Number of intentionally terminated pregnancies (regardless of the method)<br/>
Number of tubal pregnancies
Number of D&Cs (scraping uterus) as it relates to treatment for complications of pregnancy
Please specify if it was a vaginal delivery, C-Section (and any pertinent information).<br/>
