ASHIKAI GLOBAL HEALTH & WELLNESS ADVOCACY
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About
This is your pre-midwifery care survey. Please answer each question and make comments as needed.
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Indicates required field
Name
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First
Last
Email
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First Day of Last Normal Period
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Your EDD, if you know it
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General Medical Information
Do you have problems or have been diagnosed with the following?
Insulin-dependant Diabetes
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YES
NO
UNSURE
Kidney disease
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YES
NO
UNSURE
Heart disease
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YES
NO
UNSURE
Any severe medical condition or disease
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YES
NO
UNSURE
Substance use/abuse, including drugs & alcohol
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YES
NO
UNSURE
Obstetric History
How many times have you been pregnant?
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Have there been any surgeries on your reproductive system?
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YES
NO
UNSURE
Have you had three (3) or more miscarriages?
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YES
NO
UNSURE
N/A
Have you had any abortions (termination of pregnancy)?
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YES
NO
N/A
Have you had any still births or early infant losses?
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YES
NO
N/A
Was the birth weight of your last baby less than five and a half (5 1/2) pounds?
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YES
NO
N/A
Was the birth weight of your last baby more than ten (10) pounds?
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YES
NO
N/A
(General Health) Comment on any YES or UNSURE responses:
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Last pregnancy: was there a hospital admission for high blood pressure, pre-eclampsia or eclampsia?
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YES
NO
N/A
(Obstetric Health) Comment on any YES or UNSURE responses:
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Current Pregnancy
Is your age between 16 - 40 years?
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Yes
No
Has your blood pressure been running high (bottom number more than 90)?
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Yes
No
Unsure (not B/P taken)
Do you have Rh Negative Blood Type?
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Yes
No
Unsure
Have you been diagnosed as carrying more than one baby?
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Yes
No
Unsure
Have you had any vaginal bleeding during this pregnancy?
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Yes
No
Unsure
Have you been diagnosed with a pelvic mass?
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Yes
No
Unsure
Please Comment on any "Yes or Unsure" responses:
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How did you hear about this midwifery service and site?
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Internet Search
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Friend
Referral
Other
If Other please specify:
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Submit
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