Pregnancy History

If you have been pregnant please answer the following questions. In you past pregnancies have

you ever had: (Please Check if Yes)

1. Gestational Diabetes______    

2. Pregnancy Induced Hypertension______

3. Anemia______                                                                                                                  

4. Excessive Vomiting______  

5. Preterm Labor______  

6. Vaginal Bleeding______  

7. Low Amniotic Fluid______  

8. High Amniotic Fluid______          

9. Chorioamnionitis______  

10. Incompetent Cervix______  

11. Positive Group B Strep______  

12. Placental Insufficency______  

13. Large Baby at Term______                        

14. Small Baby at Term______  

15. Negative Blood Type______  

16. What is your Blood Type? ___________

17 Any Other Problem?________________________________________________________

Gynecologic History

1. Have you ever had an abnormal pap smear? Yes/No

    If yes, when and what type of treatment did you receive?

    __________________________________________________________________________

2. Have you ever been told that you have a uterine abnormality? Yes/No

3. Do you have any uterine fibroids? Yes/No

4. Did your mother take DES when she was pregnant with you? Yes/No

5.Have you had any gynecologic surgery? Yes/No

   If yes, when and what type of surgery?____________________________________________

Genetic History

Please answer the following questions. (Check if yes)

1. Will you be over 35 when you have children?  ______

    If yes, do you want genetic testing? (Amnio/CVS)______

2. Have you or your partner or anyone in either of your families had:

    Downs Syndrome______ 

    Spina Bifida or a neural tube defect______  

    Hemophilia _____ 

    Muscular Dystrophy______ 

    Cystic Fibrosis______ 

    Huntington’s Chorea______ 

3. Have you or your partner ever had a child born dead or alive with a birth

    defect not listed above?______ 

    If yes, explain:______________________________________________

4. Do you or your partner have any close relatives who are mentally retarded

    Or have birth defects?______ Explain:_________________________________

5. Do you or your partner or a close relative in either of your families have

    Any inherited genetic or chromosomal disease or disorder not listed here?______ 

    If yes, explain:______________________________________________

6. Have you had 3 or more spontaneous pregnancy losses?______ 

7. If either you and you partner are Jewish have you ever been tested for

   Tay-Sachs disease?______ If yes, results:________________________________ 

8. If either you are your partner are African American, have you ever been

    Screened for Sickle Cell Anemia?______ If yes, results:____________________ 

9. If either you or your partner are of Mediterranean descent, have you ever

   Been screened for Thalassemia (Cooley’s Anemia)______ If yes, results________ 

Habits/Environmental Factors

Please answer the following questions. (Check if yes)

1. Do you take medication either by prescription or over the counter?______ 

    If yes please list all drugs and dosages:____________________________

    ___________________________________________________________

2. Do you smoke cigarettes?______ If yes,______per day______years smoking

3. Do you drink alcohol?______ If yes, how often?______________________ 

4. Do you drink coffee or tea?______ If yes, how many cups per day?_______ 

5. Do you drink other caffeine drinks? _____If yes, how much?____________ 

6. Are you around cats?______ 

7. Do you exercise regularly?______ If yes, how often:___________________ 

8. Do you use a hot tub?______ If yes, how often?_______________________ 

9. Have you ever used illegal drugs?______ If yes, when and what drugs? 

    _____________________________________________________________ 

Infection History

Please answer the following questions. (Check if yes)

Have you had any of the following:

1. AIDS/HIV______ 

2. TB or TB Exposure______                                                                     

3. Hepatitis______ If yes, what type:______  

4. Genital Herpes______  

5. Chlamydia______  

6. Gonorrhea______  

7. Syphilis______         

8. Trichomonas______     

9. Condlyomata (Genital Warts)______  

10. Toxoplasmosis______  

11. Ever had cats______

12. Chicken Pox______  

13. Rubella (German Measles)______  

14. Other ______________________

General Medical History

Please answer the following questions. (Check if yes)

Have you or your family had any of the following:

1. Thyroid Dysfunction______Patient______Family                                                                   

2. Diabetes______Patient______Family  

3. Maternal PKU______Patient______Family  

4. Gastrointestinal problems______Patient______Family  

5. Liver disease______Patient______Family                         

6 Heart disease______Patient______Family  

7. Blood clots______Patient______Family  

8. Varicose veins______Patient______Family  

9. Rheumatic fever______Patient______Family  

10. Chronic hypertension______Patient______Family  

11. Blood disorders______Patient______Family  

12. Asthma______Patient______Family  

13. Pulmonary disease______Patient______Family  

14. Cystitis______Patient______Family  

15. Chronic renal disease______Patient______Family  

16. Chronic urinary tract infections______Patient______Family        

17. Autoimmune disease______Patient______Family  

18. Cancer______Patient______Family  

19. Neurologic seizure disorder______Patient______Family  

20. Mental disorders______Patient______Family  

21. Other (explain)____________________________________________________________

DEMOGRAPHIC INFORMATION

Patient_________________________________________________Birthdate________________Age__________

Marital Status________Race_____________Religion__________________Education Completed_______Yrs

Occupation__________________________________________________________________________________

Baby’s Father___________________________________________Birthdate_________________Age_______

Father’s Race____________________________Religion__________________Education Completed_______Yrs

Father’s Occupation____________________________________Work Phone_____________________________

Emergency Contact______________________Relationship_______________Phone________________________

Who referred you to the practice?_____________________________________________________

Why were you referred to the practice?_________________________________________________

When was the first day of your last period?______________________________________________

Are you pregnant now? If so how many weeks?___________________________________________

Have you been pregnant before? If yes please complete the following section

List all pregnancies, miscarriages and terminations:

PREGNANCY HISTORY

Have you had any miscarriages?_______________________How many?________________________

Have you had any elective terminations?________________ How many?________________________

Have you have any still births?__________________________________

Have you ever had any premature births?__________________________

Have you ever had an ectopic pregnancy?__________________________

Do you have any fertility problems?_______________________________

Is this or any pregnancy the result of infertility treatments?______________

Dr. Charles Hux

2130 Highway 35 - A123

Sea Girt, NJ 08750

Patient’s Name:___________________________________________Home Phone:_____________________

Street Address:___________________________________________________________________________

City:_____________________________State:____________________Zip Code:______________________

Age:__________Birthdate:___________________Social Security #_________________________________

Patient’s Employer_____________________________________Occupation:_________________________

Business Address:_________________________________________________________________________

City:_______________________________State:____________________Zip Code:____________________

Spouse’s Name:______________________Birthdate:__________________SS#_______________________

Spouse’s Employer_______________________________________Occupation:_______________________

Business Address:_________________________________________________________________________

City:______________________________State:______________________Zip Code:___________________

Primary Insurance Co.______________________________________________________________________

Address:____________________________________City:_____________State:_______Zip______________

ID#_______________________________________Group#________________________________________

Subscriber_________________________________Relationship_____________________________________

I expressly agree and consent to treatment provided by Shore Perinatal Associates/Dr. Charles Hux and agree to pay all and

charges for such treatment promptly. I understand that even though Shore Perinatal Associates may participate with my

insurance carrier, an amount above my co-payment may be due based on my type of insurance plan. I agree and

acknowledge that my signature on this form authorizes my physician to submit claims to my insurance carrier for services

rendered and are assignable to Shore Perinatal Associates. Payments will not be withheld because of any insurance coverage determination or pendency of claims. I also agree that in the event that you must take legal action to collect any outstanding

balance for medical services, that I will be responsible for reasonable attorney’s fees equal to 20% of the outstanding balance

or $350.00, whichever is greater and any other charges or cost the court deems proper. My signature below shall authorize

Shore Perinatal Associates to bill my credit card number that is on file with them in the event that any outstanding balance

is not paid with 90 days.

Signature_____________________________________________________Date_________________________________________

BLOOD SUGAR VALUES

PATIENT NAME: _____________________________

WEEK STARTING: ____________________________

Dr. Charles Hux

2130 Highway 35

Suite A123

Sea Girt, NJ 08750

RECORDS RELEASE REQUEST

To:_________________________________

____________________________________

____________________________________

I hereby request that all of my medical records be released and forwarded to the physician

below:

Dr. Charles Hux

2130 Highway 35

Suite A123

Sea Girt, NJ 08750

____________________________________ 

Signature

_______________________________          

Date

FACTS ABOUT IN-VITRO FERTILIZATION (IVF)

In vitro-fertilization (IVF) is part of assisted reproductive technologies (ART) which has made it possible over the last 20 years for many women to have a family, which in the past would have been impossible.

These new medical breakthroughs are not without risks and possible complications to the pregnancy and with the child or children born as a result of IVF or ART.

Many medical studies have now been published comparing normally conceived pregnancies and those resulting from IVF.

Pregnancies conceived through IVF often result in a multiple gestation of twins or triplets. These pregnancies have a higher risk for:

1. Pre term birth and complications resulting from prematurity.

2. Small or growth restricted babies.

3. Increased risk for birth defects.

4. Increased risk to the mother for diabetes and preeclampsia.

Single pregnancies from IVF have a much higher risk for pregnancy complications when compared to naturally conceived single pregnancies. These include:

IVF compared to Natural Pregnancy

1. Pregnancy loss - 2x higher

2. Pre term delivery - 2x higher

3. Low birth weight - 2x higher

4. Very low birth weight - 2x higher

5. Diabetes in mom - 2-3x higher

6. Preeclampsia in mother - 2x higher

7. Birth defects - 3x higher

8. Neonatal ICU admissions - 3x higher

The women who are pregnant through IVF are high-risk mothers and need close follow-up throughout their pregnancy.