Medical History - Place My Baby

Medical Conditions
Please give information on the medical history of you and any blood relatives, and indicate family member (e.g. your mother, father, sister, brother, aunt, uncle, etc.). Give any additional information that is appropriate such as age at onset, treatment, outcome, etc. If information is unknown ("unk”) or not available ("N/A"), please indicate.
First Name Only
1. Respiratory (Self)
Yes No
Allergies
Asthma
Bronchitis
Emphysema
Tuberculosis
Cystic Fibrosis
(Family)
Yes No
Allergies
Asthma
Bronchitis
Emphysema
Tuberculosis
Cystic Fibrosis
Comments (indicate family member etc)
2. Gastrointestinal (self)
Yes No
Ulcers
Inflammatory Bowel
Cleft Lip or Palate
Other
(Family)
Yes No
Ulcers
Inflammatory Bowel
Cleft Lip or Palate
Other
Comments (indicate family member etc)
3. Cardiovascular (self)
Yes No
High Blood Pressure
Heart Attack
Stroke
Congestive Heart Failure
Atherosclerosis
Heart Rhythm Abnormality
Congenital Heart Defect
(Family)
Yes No
High Blood Pressure
Heart Attack
Stroke
Congestive Heart Failure
Atherosclerosis
Heart Rhythm Abnormality
Congenital Heart Defect
Comments (indicate family member etc)
4. Immune/Hematological Condition (self)
Yes No
Mononucleosis
Hemophilia
Leukemia
Lymphomas
Hodgkin's Disease
Lupus
(Family)
Yes No
Mononucleosis
Hemophilia
Leukemia
Lymphomas
Hodgkin's Disease
Lupus
Comments (indicate family member etc)
5. Renal Condition (self)
Yes No
Kidney Failure / Dialysis / Transplant
Other Kidney
(Family)
Yes No
Kidney Failure / Dialysis / Transplant
Other Kidney
Comments (indicate family member etc)
6. Liver Disease (self)
Yes No
Hepatitis (specify)
Cirrhosis
Other Liver Disease
(Family)
Yes No
Hepatitis (specify)
Cirrhosis
Other Liver Disease
Comments (indicate family member etc)
7. Central Nervous System Condition (self)
Yes No
Epilepsy
Cirrhosis Hydrocephalus
Multiple Sclerosis
Huntington's Chorea
Seizures / Convulsions
(Family)
Yes No
Epilepsy
Cirrhosis Hydrocephalus
Multiple Sclerosis
Huntington's Chorea
Seizures / Convulsions
Comments (indicate family member etc)
8. Endocrine (self)
Yes No
Diabetes (Adult or Juvenile)
Thyroid (Hyper/Hypo)
Adrenal
(Family)
Yes No
Diabetes (Adult or Juvenile)
Thyroid (Hyper/Hypo)
Adrenal
Comments (indicate family member etc)
9. Muscular/Skeletal (self)
Yes No
Club Foot
Scoliosis
Arthritis (Osteo or Rheumatoid)
Lupus
(Family)
Yes No
Club Foot
Scoliosis
Arthritis (Osteo or Rheumatoid)
Lupus
Comments (indicate family member etc)
10. Neuromuscular (self)
Yes No
Cerebral Palsy
Muscular Dystrophy
Spina Bifida
(Family)
Yes No
Cerebral Palsy
Muscular Dystrophy
Spina Bifida
Comments (indicate family member etc)
11. Visual/Auditory (self)
Yes No
Blindness
Glaucoma
Cataracts
Deafness or Other Hearing Problems
(Family)
Yes No
Blindness
Glaucoma
Cataracts
Deafness or Other Hearing Problems
Comments (indicate family member etc)
12. Mental and Behavioral Disorders (self)
Yes No
Diagnosed Schizophrenia
Diagnosed Bi-Polar
Other Mental Illness (Describe)
(Family)
Yes No
Diagnosed Schizophrenia
Diagnosed Bi-Polar
Other Mental Illness (Describe)
Comments (indicate family member etc)
13. Lymphatic Disorders (self)
Yes No
Cancer
Tumors
Cystic Fibrosis
Hodgkins Disease
(Family)
Yes No
Cancer
Tumors
Cystic Fibrosis
Hodgkins Disease
Comments (indicate family member etc)
14. Drugs Taken During This Pregnancy
Yes No
a. Prescription Drugs
Details
Name When How Often Amount

Click on + button to add more than one
Yes No
a. Non-Prescription Drugs (include asprin, nosedrops, etc)
Details
Name When How Often Amount

Click on + button to add more than one
c. Alcohol and other substances
Yes No
1. Alcohol (wine, beer, etc)
Details
When How Often Amount
Yes No
2. Amphetamines (uppers)
Details
When How Often Amount
Yes No
3. Barbiturates (downers)
Details
When How Often Amount
Yes No
4. Tobacco
Details
When How Often Amount
Yes No
5. Cocaine
Details
When How Often Amount
Yes No
6. Crack
Details
When How Often Amount
Yes No
7. Heroin
Details
When How Often Amount
Yes No
8. LSD
Details
When How Often Amount
Yes No
9. PCP
Details
When How Often Amount
Yes No
10. Marijuana
Details
When How Often Amount
Yes No
11. Other (specify)
Details
When How Often Amount
Other:
When finished Push Submit – do not push the done button

	Yes	No
Allergies
Asthma
Bronchitis
Emphysema
Tuberculosis
Cystic Fibrosis

	Yes	No
High Blood Pressure
Heart Attack
Stroke
Congestive Heart Failure
Atherosclerosis
Heart Rhythm Abnormality
Congenital Heart Defect

	Yes	No
Mononucleosis
Hemophilia
Leukemia
Lymphomas
Hodgkin's Disease
Lupus

	Yes	No
Epilepsy
Cirrhosis Hydrocephalus
Multiple Sclerosis
Huntington's Chorea
Seizures / Convulsions

	Yes	No
Diabetes (Adult or Juvenile)
Thyroid (Hyper/Hypo)
Adrenal

	Yes	No
Blindness
Glaucoma
Cataracts
Deafness or Other Hearing Problems

	Yes	No
Diagnosed Schizophrenia
Diagnosed Bi-Polar
Other Mental Illness (Describe)

	Yes	No
a. Non-Prescription Drugs (include asprin, nosedrops, etc)

	Yes	No
Ulcers
Inflammatory Bowel
Cleft Lip or Palate
Other

	Yes	No
Ulcers
Inflammatory Bowel
Cleft Lip or Palate
Other

	Yes	No
Kidney Failure / Dialysis / Transplant
Other Kidney

	Yes	No
Kidney Failure / Dialysis / Transplant
Other Kidney

Medical Conditions