《懷孕40週全書》婦科/產科健康問卷調查範本
除了妳的姓名，地址，電話號碼及健康保險等基本資料外，希望妳能將妳的健康情形以及生活型態等，一併提供給醫師做為評估及參考。此外，最好能在做第一次產檢之前完成填表，讓妳有充分的時間檢視自己，也了解自己還有哪些地方不確定，不了解，需要再學習，或需要與醫師詳加討論的。每個問題旁所附之參考頁數，能讓妳更深入的了解這個議題。
Sample OB/GYN Questionnaire
In addition to your name, address, phone number and insurance information, your healthcare provider will need information about your health and lifestyle. If you fill it out before you go to your
first appointment, you’ll have time to think about what you need to know or are unsure of. Read the pages listed next to each question for more information about that particular issue.
妳覺得自己懷孕了嗎？□是 □不是 □不確定
Do you think you are currently Pregnant?□ yes□ no□ unsure
健康資料 Health History
家族遺傳病史 Genetic
Check if any of the following apply List drugs you are allergic to: to you or anyone in your family.See the page listed next to each condition for information on that condition and how it relates to pregnancy.
仔細檢查看看，自己或者自己的家族裡，是否曾出現下列疾病。疾病旁出現的參考頁數，能讓妳了解這個疾病，及可能對懷孕造成的影響。
□ Birth defects (see pages 17,164)先天缺陷或畸形（見17,164頁）
□ Cystic fibrosis (seepage 17) 纖維囊泡症
□ Down syndrome(see pages 17, 19, 125, 164, 171) 唐氏症
□ Hemophilia (see pages 17,164) 血友病
□ Huntington’s chorea亨丁頓氏舞蹈症
□ Hydrocephalus(see pages 125, 184) 水腦症
□ Muscular dystrophy(see page 17) 肌肉萎縮症
□ Sickle cell trait/disease(see pages 17,164, 210) 鎌狀細胞症危象
□ Spina bifida/anencephaly(see pages 17, 156, 164) 脊柱裂/先天無腦無脊髓畸形
□ Tay-Sachs (see page 17)黑矇性家族性白癡，泰賽二氏症
□ Thalassemia (seepage 212) 地中海貧血
□ Other:其他
Medical 妳及家族的醫療資料
□ Anemia (see pages 10,210) 貧血
□ Asthma (see pages 10,261) 氣喘
□ Blood disease/transfusion(see page 193) 血液疾病/曾經輸過血
□ Cancer (see pages 11, 138, 158, 277) 癌症
□ Cardiac (heart) disease(see page 13) 心臟疾病
□ Diabetes mellitus (see pages 11,220) 糖尿病
□ Drug allergy 藥物過敏
List drugs you allergic to 詳列妳會過敏的藥物：
□ Gastrointestinal disease 胃腸疾病
□ HIV (see page 81) 人類免疫缺陷病毒，愛滋病
□ Hypertension (high blood pressure) (see pages 13,287) 高血壓
□ Kidney and bladder problems(see pages 11, 181) 腎臟及膀胱的問題
□ Liver disease 肝臟的疾病
□ Lung disease 肺臟的疾病
□ Lupus (see pages 13, 255) 紅斑性狼瘡
□ Organ transplant 器官移植
□ Psychiatric disease 精神疾病
□ Seizure disorder (see pages 12,243) 抽搐疾病
□ Stroke 中風
□ Surgeries 外科手術
□ Thyroid disease (see pages 14,236) 甲狀腺疾病
□ Venous thrombosis/pulmonary embolism (see page 199) 靜脈栓塞/肺栓塞
□ Other其他:
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產科危險因子（產科史） Obstetric Risk Factors (Pregnancy History)
Check if any of the following applied to you (not your family) during a previous pregnancy. See the page listed next to each risk factor for further information.
注意，下面的情況，則是跟妳自己有關（跟妳的家人沒有關係），在妳的前幾次懷孕當中，是否曾經出現下列狀況。可參考各個危險因子旁所附的頁數，做更進一步的了解。
□ Abortion 流產
□ Abruption (see page 301) 胎盤早期剝離
□ Age 35 or older at time of delivery (see page 18) 分娩時，年齡超過35歲
□ Antibody sensitization 抗體過敏反應
□ Fetal distress in labor(see pages 296, 345) 分娩時出現胎兒窘迫症
□ Fetus or infant had a birth defect 胎兒或者嬰兒出現先天畸形
□ Incompetent cervix (see page 229) 子宮頸閉鎖不全
□ Infant admitted to NICU 嬰兒曾住過嬰兒加護病房
□ Infant heavier than 9 pounds at birth 嬰兒出生體重超過9磅
□ Infant with IUGR (see page 281) 胎兒曾出現胎兒子宮內生長遲滯
□ Multiple gestation (see page 292) 多胎妊娠
□ Placenta previa (see page 325) 前置胎盤
□ Poly/oligohydramnios(see page 227) 羊水過多/羊水過少
□ Pre-eclampsia (seepage 288) 子癇前症
□ Previous Cesarean section(see page 331) 曾剖腹生產
Uterine incision type:子宮手術方式
□ Prior preterm birth (37 weeks or less) (see page 266) 曾早產（孕期少於37週）
□ Recurrent urinary-tract infection(see pages 11, 181) 泌尿道的感染反覆發作
□ Stillbirth/neonatal death(see page 94) 死產/胎死腹中
□ Other:其他
不足月早產的危險因子 Risk Factors for Preterm Birth
Check if any of the following applies to you. See the page listed next to each risk factor for more information on that factor.
本欄主要是檢視妳是否具有不足月早產的危險因素。翻閱旁邊的頁數，可提供妳更詳盡的資料。
□ 2 or more abortions requiring D&C (see pages 94,111, 229) 2胎或者2胎以上曾經需要做墮胎手 術
□ African American 非洲裔
□ DES exposure 曾接觸或服用過量二乙基合成雌性激素
□ Drug abuse (including alcohol)(see pages 23, 40, 60) 藥物濫用，嗑藥
□ History of sexually transmitted diseases (see pages 26, 78) 曾罹患性病
□ Known uterine malformation 已知有子宮畸形或子宮異常
□ Older than 35 years old (see page 18) 年齡超過35歲
□ Previous uterine surgery 子宮曾開過刀
□ Prior preterm birth (37 weeks or less) (see page 266) 之前曾經早產（小於或等於37週）
□ Psychosocial/physical abuse 曾遭受心理或生理的虐待
□ Smoking (see pages 24,38) 抽煙
□ Weight: less than 55 kg (121 Ibs) 體重低於55公斤（約121磅）
□ Younger than 18 years old 小於18歲
□ Other其他:
其他小孩的狀況 Other Children
Fill in the following information about other children you have, starting with the oldest.
詳實敘述妳其他孩子的情形，並請依年齡大小順序排列
1. Name姓名:
Birthdate出生年月日：
Birth hospital and city出生醫院及城市：
Sex性別：
Weight at birth出生體重：
Gestational age at birth出生時的懷孕週數：
Maternal age出生時，母親的年齡：
Labor length分娩的時間，花了多久：
Anesthesia used是否有使用麻醉：
Delivery type生產的方式為何：
Maternal problems母親當時有無問題：
Newborn problems新生兒出世時，有無問題：
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藥物 Medications
Please list all medications you currently take, recently stopped taking or plan to take:
請將妳現在正在服用的，最近曾經服用過的，或者計劃要服用的所有藥物寫下
Medication藥品名稱:
Dosage劑量：
Start date開始服用日期：
Stop date (if any)如果停藥，請寫下停藥時間及日期：
Do you regularly take any over-the-counter medications, vitamins, minerals, herbs or other supplements? Please list them below.
妳有按時服用哪些成藥，維生素，礦物質，中藥，藥草，或者其他補充劑？請詳細列明藥品名稱
妳的生活型態 Lifestyle
‧Do you use tobacco? (see pages 24,38) 妳抽煙嗎？
‧How much alcohol do you drink per week? (see pages 24, 40, 59, 62) 妳每週大概會喝多少酒？
‧Do you take any drugs that aren’t prescribed for you? (see pages 23,60) 妳有沒有服用任何 非處方藥？
‧If yes, what kind(s)? 如果有，是哪些藥？
‧How often? 吃過多少次？
‧How much caffeine do you ingest per day (including chocolate, coffee, soda, caffeinated tea)? (see pages 62,141) 妳每天會接觸多少咖啡因？喝幾杯咖啡？（包括巧克力，咖啡，可樂，及含 咖啡因飲料）
‧Are you currently trying to lose weight? (see page 20) 妳最近曾經試著減重嗎？
‧Are you currently trying to gain weight? (see page 20) 妳最曾經嘗試增加體重嗎？
‧How often do you exercise? 妳多久運動一次？
‧What kind of exercise? (see page 50) 妳都做哪些運動？
‧What do you do for a living? (see pages 25, 139) 妳做什麼工作？
‧Are you exposed to any chemicals in the workplace? (see pages 25, 64) 妳工作的環境，會不 會接觸任何化學物質？
‧Do you lift heavy objects or stand for long periods of time? (see pages 25,141)妳需要舉重物，或長時間站立嗎？
‧What kind of contraception are you currently using, if any? (see pages 5,69) 妳有沒有避孕，如果有，是採用哪種避孕方法？
‧What was the date of the start of your last period? 最後一次來月經的日期為何
‧Have you ever been tested for any sexually transmitted diseases(STDs)? (see pages 26, 78) 妳有沒有做過任何性病的篩檢檢驗？
‧If so, when and what were the results? 如果有，什麼時候做的？結果如何？
‧If not, have you ever placed yourself at risk for an STD? (seepages 26, 78) 如果沒做過檢驗，那妳是否曾經有過不安全（可能會感染性病）的性行為？
‧Has your partner been tested for any STDs? 妳的性伴侶做過性病的檢驗嗎？
‧If so, when and what were the results? 如果做過，什麼時候做的？結果如何？
‧If not, has he ever placed himself at risk for an STD? 如果沒做過，他是否有過不安全（可能會感染性病）的性行為？
‧Have you ever been tested for H IV? (see page 81) 妳有沒有做過愛滋病的檢驗？
‧If so, when and what were the results? 如果有，什麼時候做的？結果如何？
‧If not, have you ever risked exposure to HIV? (see page 81) 如果沒做過檢驗，那妳是否曾經有過不安全（可能會感染愛滋病）的性行為？
‧Has your partner ever been tested for HIV? 妳的性伴侶做過愛滋病病的檢驗嗎？
‧If so, when and what were the results? 如果做過，什麼時候做的？結果如何？
‧If not, has he ever risked exposure to HIV? 如果沒做過檢驗，那他是否曾經有過不安全（可能會感染愛滋病）的性行為？
Please list any medical tests (including X-rays, CT scans, MRIs and anything else involving radiation) you’ve had in the past 6 months最近6個月內，是否做過任何放射線檢查（包括各種X光檢查，電腦斷層掃描，核磁共振造影檢查等）:
Test檢查名稱：
Date做檢查日期：
Test檢查名稱：
Date做檢查日期：
Test檢查名稱：
Date做檢查日期：
Do you plan to take any medical tests in the near future? When? Why? 妳最近有安排做任何檢查嗎？為什麼要做？什麼時候做？
Please list any vaccinations you’ve had in the past 6 months: 過去6個月內，是否曾經接受疫苗注射？
Vac.疫苗名稱：
Date接種日期：
Vac.疫苗名稱：
Date接種日期：
Vac.疫苗名稱：
Date接種日期：
Do you plan to have any vaccinations in the near future? When? Why? 妳計劃最近接受疫苗注射嗎？什麼時候？為什麼？
Please list any questions or concerns you have about your current or future pregnancy:
關於妳這次懷孕的疑問與疑慮，或者妳擔心將來再次懷孕時，可能會產生的問題或者擔心，全部寫下來。
摘自：《懷孕40週全書》新手父母出版＠(//www.dajiyuan.com)