Prince Al-Hussein Bin Abdullah II Academy

Of Civil Protection

Obstetrical History Form

Name -----------------------------------------------------Date ---------------

Age -------------------------Date of Birth---------------- Occupation -------------------

Marital Status:SingleMarriedDivorcedWidowed

----------------------------------------------- :Date of First Prenatal Visit

---------------------------------------- Estimated gestational age (EGA)

------------------------------------------------ :Estimated Due of delivery

Medical Conditions
Diabetes Obesity Hypertension Asthma STD HIV
___________________________________________________ Other

Behavioral Status
Anxiety Depression Other psychiatric diagnosis SUD Smoking
_____________________________________________Other

-------------------------------------------- :Name of the father of the baby

--------------------------------------- ?What was the first day of your last normal period

Do you normally have a period every month?YesNo Every-------- days

PAST OBSTETRICAL HISTORY(List all pregnancies including miscarriages, abortions, tubal/ectopic)

Gravida Term Preterm Abortion Living Multiple

births births Children births