1 Moondance Midwifery, meg@moondancemidwifery.

com, 512-629-0576

Moondance Midwifery
Medical / Health History
Please fill out this personal history carefully. At your next visit we will review this history together
and go over any questions you might have. If there are any technical terms or sections on which you
are unclear, please leave them blank.
Personal Information
Date __________________________
Your Name _____________________________________________ Phone ________________
Address _________________________________________ Occupation _____________________
Date of Birth ___________________ Height __________ Usual Weight _____________________
Partner's Name ___________________________________ Date of Birth ___________________
Address (if different) __________________________________________________________
Emergency Contact ______________________________________ Phone __________________
Who Referred You? _________________________________________________
Insurance? ________________________________ Pediatrician _________________________
Do you have any drug allergies or sensitivities? _________________________________________
Menstrual History
When do you think you may have conceived? ____________________________________
How long is your menstrual cycle? ________________________________
LMP last menstrual period _________________________________
Was it normal in length and heaviness of flow? (Circle) Yes No
Did you have a pregnancy test? Yes No
Was this a planned pregnancy? Yes No
PMP Previous menstrual period ______________________________
Were you using birth control when you conceived? Yes No
If so, what kind? ______________________
Any complications after abortion or miscarriage?
____ Pain _______ Infection ___________Incomplete _________ Emotional Trauma
If Rh negative, did you receive RhoGAM? ____ Yes _____ No
Please list information about your previous births:
Date
# of Weeks
Length of
Sex M / F
Place of Birth Complications
Mo / Yr
Labor

Comments on labor/birth complications

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2 Moondance Midwifery, meg@moondancemidwifery.com, 512-629-0576

Medical History
Please circle if you have had any of the following conditions. In the area below, please record date,
treatment, and any follow-up that you received. Also please list any additional important conditions
or concerns.
Kidney disease, Diabetes, Hypertension, Epilepsy, Heart Disease, Thyroid problems, Blood clotting
problems, Asthma, Hepatitis, Liver Problems, Tuberculosis, Urinary tract surgery, Pelvic / back
injuries, Stomach Problems, Bowel problems, Skin problems, Bladder infection, Anemia,
Hospitalizations, Seizures, Surgeries, Hemorrhage, Allergies, Severe headaches, Dental problems,
Phlebitis / Varicosities, Hemorrhoids
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Is there any hereditary disease or condition in your family such as diabetes, cancer, heart disease,
hypertension? (List and indicate in which relative.)
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Lab Work (please leave blank)
Initial Labs
Date

Result

Blood Type

AB

D (Rh) Type
Antibody Screen
HCT / HGB

________% __________ g / dL

PAP Test

Normal / Abnormal / _________

Rubella
VDRL
Urine Culture / Screen
Hbs Ag
HIV Counseling / Testing
PPD
Chlamydia
GC
Tay-Sachs
Other
8-18 Week Labs
AFP

Date

Result

3 Moondance Midwifery, meg@moondancemidwifery.com, 512-629-0576

Amnio / CVS
24-28 Week Labs

Date

Result

HCT / HGB

______%_________g/dL

Diabetes Screen

1 hour ____________

GTT (if screen Abnormal)

_____ FBS _________ 1 hr ______2 hr

_______3 hr

D (Rh) Antibody Screen

32-36 Week Labs

Date

HCT / HGB

Result
______% _______ g/dL

Group B Strep (35-37 wks)

Have you or the father of your baby ever had a baby with a birth defect for mental retardation?Y / N
Do you or the father of your baby have any family members with birth defects or conditions
diagnosed as genetic or inherited? Y /N
Are you and the father of your baby related by blood? (eg. Cousins) Y / N
Certain genetic problems may occur in the following ethnic / racial groups. Are you or the father of
your baby: (please circle)
Jewish

Black / African

Asian

Northern European

Mediterranean

How many times was your mother pregnant?____________ How many babies did she have?
____________________________ Did she have any miscarriages? _______________________
How long were her labors? _________________________ Were there complications in any of her
pregnancies? ________________________________How much did you weigh at birth? ________
What did your mother tell you about the birth?
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Do you suffer from recurrent anxiety or depression? Y / N
Have you ever had anorexia, bulimia, or eating problems? Y / N
Have you ever been in an abusive relationship, including now, or been abused in the past (physically
or emotionally intimidated, beaten, injured)? Y/ N
Do you feel you have ever been subject to gynecological or obstetrical abuse? Y / N
Have you ever had non-consensual sex? Y / N
Do you think, or has anyone ever told you, that you have used drugs or alcohol excessively? Y / N
Have you ever used IV drugs? Y / N
Have you ever had a blood transfusion? Year ________
Do you think you are at increased risk for HIV / AIDS ? Y / N
Do you want information about safer sex practices? Y / N
Gynecological / Contraceptive History
When was your last PAP smear? ___________________________________
Have you ever had an abnormal PAP? If so, when? _____________________________ How was it
resolved? __________________________________________
Do you perform breast self exams? ____________________________________

4 Moondance Midwifery, meg@moondancemidwifery.com, 512-629-0576

Please circle if you've ever had any of the following:
Yeast, Bacterial Vaginosis, Syphilis, Genital Herpes, Cervicitis, Ovarian Cyst, Abnormal Bleeding,
Breast surgery, Trichomonas, Chlamydia, PID, Oral Herpes, Cervical surgery, Fibroids, Uterine
Surgery, Infertility, Gardnerella, Gonorrhea, Vaginal Surgery, Genital Sores, Condyloma (warts), HPV
(human papilloma virus), Cervical polyp, Endometriosis, Breast lumps, Other reproductive problems
or conditions
Have you ever used birth control? If so, what kind? Did you have any problems or complications?
Please describe below.
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Current Pregnancy
What prenatal care have you had up to the present? Please list doctors, clinics, and hospitals where
you have had care, what was done, and especially if you have had any lab work or special testing
done.
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Please circle if you've had any of the following problems during this pregnancy:
Nausea, Headache, Leg Cramps, Swelling, Urinary Problems, Vaginal Discharge, Indigestion,
Vomiting, Dizziness, Fever, Rash, Bleeding gums, Constipation, Hemorrhoids, Abdominal / pelvic
pain, Vaginal bleeding / spotting, Varicose veins, Backache, Diarrhea, Family problems, Loneliness,
Relationship problems, Depression, Work problems
Have you used or been exposed to any of the following during this pregnancy?
Tobacco, Caffeine, Alcohol, Marijuana, Cocaine, Street drugs, Viruses, Measles, Cats, Vaccinations,
Ultrasounds, X rays, Herbs, Vitamins, Non-prescription drugs, Prescription drugs, Fumes / sprays,
Other environmental hazards
How would you describe your usual diet? _______________________________
What do you generally do for exercise? __________________________________________
How do you feel about this pregnancy? ___________________________________________
How does your partner feel about this pregnancy? ______________________________________
Do you feel that your sexual life has changed considerable since you became pregnant?
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Do you plan to breastfeed your baby, if so, for how long?
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Are there any particular ethnic, cultural, or religious preferences for your care that you would like to
discuss?
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5 Moondance Midwifery, meg@moondancemidwifery.com, 512-629-0576

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Do you feel you have the adequate resources, ie. Food, shelter, money, for this pregnancy?
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Do you have a car seat for the baby yet? ________________________
Please list the people you plan to invite to your birth.
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Have you faced any opposition to your plans for a home birth?
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In general, how do you cope with stress? How do you cope with pain?
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Please give some thought to the following questions and record your ideas. If you and your partner
are together, you can each write your answers. Please read all questions before beginning your
answers:
Why do you want to have this baby at home?
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Partner:
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What do you see as the duties or responsibilities of your midwife?
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Partner:
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There are things that can go wrong without previous warning during labor, birth, and the postpartum
period. If you are a low risk woman, the chances of complications are low. However, if such
complications should occur, you or your baby could be at greater risk at home. There are risks
involved in childbirth, just as there are in driving a car. It is likely that humankind will never be able
to eliminate some of these risks. There is a certain set of risks that are higher in a hospital setting, and
certain risks that are higher at home or in an alternative birthing center. If you choose the risks
involved in home birth you should know what they are and how they can be dealt with. Please
comment here about what you know of these risks and complications and what your feelings are
about them.
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6 Moondance Midwifery, meg@moondancemidwifery.com, 512-629-0576

Partner___________________________________________________________________________
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How do you feel about going to the hospital to deliver if your midwife determines that complications
are arising?
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Partner
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How do you think you would deal with the problem of a baby or a mother who suffered permanent
injury or died at home?
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Partner
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What do you think are the benefits of having your baby at home?
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Partner___________________________________________________________________________
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Please add any comments or thoughts that you think might be important for your midwife to know
about you:
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