Pregnancy History

Last Name

First Name

Please include Miscarriages

1st Pregnancy

Live Birth?

Yes No

Type of delivery (Circle One)

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

2nd Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

3rd Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

4th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

5th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

6th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

7th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

8th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

9th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

10th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

11th Pregnancy

Live Birth

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

12th Pregnancy

Live Birth?

Yes No

Type of delivery

vag c-section

Date of Birth or Miscarriage

Weight

Complications?

Did newborn have any problems?

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