Prenatal Screening Questionnaire Form

Please fill out the form to facilitate the prenatal screening process. It will take about 10 minutes.

Need help? Contact us at 732 555 556 during working hours (Monday-Friday 8:00 AM - 9:00 PM).

Personal Data

First Name

Last Name

Contact Phone

Email Address

Date of Birth

Blood Group

Don't remember

Biophysical Profile

Current Weight

Height

Smoking During Pregnancy

How many cigarettes do you smoke per day?

Diabetes

Chronic Hypertension

Lupus Erythematosus

Antiphospholipid Syndrome

Pre-eclampsia in Pregnant Mother

Pregnancy and Birth History

Which pregnancy is this currently?

How many births have you had in total?

Live births above 37 weeks

Live births below 37 weeks

Neonatal deaths above 37 weeks

Neonatal deaths below 37 weeks

Number of miscarriages below 23 weeks

Number of stillbirths above 23 weeks

Number of ectopic (extrauterine) pregnancies

Last birth week of pregnancy

Don't remember

Date of last birth

Don't remember

Low birth weight in previous pregnancy (below 2500g)

Genetic Defect

Description of genetic defect

Pre-eclampsia in previous pregnancy

Current Medications

Neoparin / Clexane

When did you start taking Neoparin / Clexane?

Don't remember

Acard

When did you start taking Acard?

Don't remember

Current Pregnancy Information Select dating method:

Last menstrual period date

Estimated date of delivery

Don't remember

Last menstrual period date

Estimated date of delivery

Method of conception

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