除了你的姓名，地址，电话号码及健康保险等基本资料外，希望你能将你的健康情形以及生活型态等，一并提供给医师做为评估及参考。此外，最好能在做第一次产检之前完成填表，让你有充分的时间检视自己，也了解自己还有哪些地方不确定，不了解，需要再学习，或需要与医师详加讨论的。每个问题旁所附之参考页数，能让你更深入的了解这个议题。
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.
你觉得自己怀孕了吗？□是 □不是 □不确定
Do you think you are currently Pregnant?□ yes□ no□ unsure
健康资料 Health History
家族遗传病史 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.
仔细检查看看，自己或者自己的家族里，是否曾出现下列疾病。疾病旁出现的参考页数，能让你了解这个疾病，及可能对怀孕造成的影响。
□ Birth defects (see pages 17,164)先天缺陷或畸形（见17,164页）
□ Cystic fibrosis (seepage 17) 纤维囊泡症
□ Down syndrome(see pages 17, 19, 125, 164, 171) 唐氏症
□ Hemophilia (see pages 17,164) 血友病
□ Huntington’s chorea亨丁顿氏舞蹈症
□ Hydrocephalus(see pages 125, 184) 水脑症
□ Muscular dystrophy(see page 17) 肌肉萎缩症
□ Sickle cell trait/disease(see pages 17,164, 210) 镰状细胞症危象
□ Spina bifida/anencephaly(see pages 17, 156, 164) 脊柱裂/先天无脑无脊髓畸形
□ Tay-Sachs (see page 17)黑蒙性家族性白痴，泰赛二氏症
□ Thalassemia (seepage 212) 地中海贫血
□ Other:其他
Medical 你及家族的医疗资料
□ Anemia (see pages 10,210) 贫血
□ Asthma (see pages 10,261) 气喘
□ Blood disease/transfusion(see page 193) 血液疾病/曾经输过血
□ Cancer (see pages 11, 138, 158, 277) 癌症
□ Cardiac (heart) disease(see page 13) 心脏疾病
□ Diabetes mellitus (see pages 11,220) 糖尿病
□ Drug allergy 药物过敏
List drugs you allergic to 详列你会过敏的药物：
□ Gastrointestinal disease 胃肠疾病
□ HIV (see page 81) 人类免疫缺陷病毒，爱滋病
□ Hypertension (high blood pressure) (see pages 13,287) 高血压
□ Kidney and bladder problems(see pages 11, 181) 肾脏及膀胱的问题
□ Liver disease 肝脏的疾病
□ Lung disease 肺脏的疾病
□ Lupus (see pages 13, 255) 红斑性狼疮
□ Organ transplant 器官移植
□ Psychiatric disease 精神疾病
□ Seizure disorder (see pages 12,243) 抽搐疾病
□ Stroke 中风
□ Surgeries 外科手术
□ Thyroid disease (see pages 14,236) 甲状腺疾病
□ Venous thrombosis/pulmonary embolism (see page 199) 静脉栓塞/肺栓塞
□ Other其他:
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产科危险因子（产科史） 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，下面的情况，则是跟你自己有关（跟你的家人没有关系），在你的前几次怀孕当中，是否曾经出现下列状况。可参考各个危险因子旁所附的页数，做更进一步的了解。
□ Abortion 流产
□ Abruption (see page 301) 胎盘早期剥离
□ Age 35 or older at time of delivery (see page 18) 分娩时，年龄超过35岁
□ Antibody sensitization 抗体过敏反应
□ Fetal distress in labor(see pages 296, 345) 分娩时出现胎儿窘迫症
□ Fetus or infant had a birth defect 胎儿或者婴儿出现先天畸形
□ Incompetent cervix (see page 229) 子宫颈闭锁不全
□ Infant admitted to NICU 婴儿曾住过婴儿加护病房
□ Infant heavier than 9 pounds at birth 婴儿出生体重超过9磅
□ Infant with IUGR (see page 281) 胎儿曾出现胎儿子宫内生长迟滞
□ Multiple gestation (see page 292) 多胎妊娠
□ Placenta previa (see page 325) 前置胎盘
□ Poly/oligohydramnios(see page 227) 羊水过多/羊水过少
□ Pre-eclampsia (seepage 288) 子痫前症
□ Previous Cesarean section(see page 331) 曾剖腹生产
Uterine incision type:子宫手术方式
□ Prior preterm birth (37 weeks or less) (see page 266) 曾早产（孕期少于37周）
□ Recurrent urinary-tract infection(see pages 11, 181) 泌尿道的感染反复发作
□ Stillbirth/neonatal death(see page 94) 死产/胎死腹中
□ Other:其他
不足月早产的危险因子 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.
本栏主要是检视你是否具有不足月早产的危险因素。翻阅旁边的页数，可提供你更详尽的资料。
□ 2 or more abortions requiring D&C (see pages 94,111, 229) 2胎或者2胎以上曾经需要做堕胎手 术
□ African American 非洲裔
□ DES exposure 曾接触或服用过量二乙基合成雌性激素
□ Drug abuse (including alcohol)(see pages 23, 40, 60) 药物滥用，嗑药
□ History of sexually transmitted diseases (see pages 26, 78) 曾罹患性病
□ Known uterine malformation 已知有子宫畸形或子宫异常
□ Older than 35 years old (see page 18) 年龄超过35岁
□ Previous uterine surgery 子宫曾开过刀
□ Prior preterm birth (37 weeks or less) (see page 266) 之前曾经早产（小于或等于37周）
□ Psychosocial/physical abuse 曾遭受心理或生理的虐待
□ Smoking (see pages 24,38) 抽烟
□ Weight: less than 55 kg (121 Ibs) 体重低于55公斤（约121磅）
□ Younger than 18 years old 小于18岁
□ Other其他:
其他小孩的状况 Other Children
Fill in the following information about other children you have, starting with the oldest.
详实叙述你其他孩子的情形，并请依年龄大小顺序排列
1. Name姓名:
Birthdate出生年月日：
Birth hospital and city出生医院及城市：
Sex性别：
Weight at birth出生体重：
Gestational age at birth出生时的怀孕周数：
Maternal age出生时，母亲的年龄：
Labor length分娩的时间，花了多久：
Anesthesia used是否有使用麻醉：
Delivery type生产的方式为何：
Maternal problems母亲当时有无问题：
Newborn problems新生儿出世时，有无问题：
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药物 Medications
Please list all medications you currently take, recently stopped taking or plan to take:
请将你现在正在服用的，最近曾经服用过的，或者计划要服用的所有药物写下
Medication药品名称:
Dosage剂量：
Start date开始服用日期：
Stop date (if any)如果停药，请写下停药时间及日期：
Do you regularly take any over-the-counter medications, vitamins, minerals, herbs or other supplements? Please list them below.
你有按时服用哪些成药，维生素，矿物质，中药，药草，或者其他补充剂？请详细列明药品名称
你的生活型态 Lifestyle
‧Do you use tobacco? (see pages 24,38) 你抽烟吗？
‧How much alcohol do you drink per week? (see pages 24, 40, 59, 62) 你每周大概会喝多少酒？
‧Do you take any drugs that aren’t prescribed for you? (see pages 23,60) 你有没有服用任何 非处方药？
‧If yes, what kind(s)? 如果有，是哪些药？
‧How often? 吃过多少次？
‧How much caffeine do you ingest per day (including chocolate, coffee, soda, caffeinated tea)? (see pages 62,141) 你每天会接触多少咖啡因？喝几杯咖啡？（包括巧克力，咖啡，可乐，及含 咖啡因饮料）
‧Are you currently trying to lose weight? (see page 20) 你最近曾经试着减重吗？
‧Are you currently trying to gain weight? (see page 20) 你最曾经尝试增加体重吗？
‧How often do you exercise? 你多久运动一次？
‧What kind of exercise? (see page 50) 你都做哪些运动？
‧What do you do for a living? (see pages 25, 139) 你做什么工作？
‧Are you exposed to any chemicals in the workplace? (see pages 25, 64) 你工作的环境，会不 会接触任何化学物质？
‧Do you lift heavy objects or stand for long periods of time? (see pages 25,141)你需要举重物，或长时间站立吗？
‧What kind of contraception are you currently using, if any? (see pages 5,69) 你有没有避孕，如果有，是采用哪种避孕方法？
‧What was the date of the start of your last period? 最后一次来月经的日期为何
‧Have you ever been tested for any sexually transmitted diseases(STDs)? (see pages 26, 78) 你有没有做过任何性病的筛检检验？
‧If so, when and what were the results? 如果有，什么时候做的？结果如何？
‧If not, have you ever placed yourself at risk for an STD? (seepages 26, 78) 如果没做过检验，那你是否曾经有过不安全（可能会感染性病）的性行为？
‧Has your partner been tested for any STDs? 你的性伴侣做过性病的检验吗？
‧If so, when and what were the results? 如果做过，什么时候做的？结果如何？
‧If not, has he ever placed himself at risk for an STD? 如果没做过，他是否有过不安全（可能会感染性病）的性行为？
‧Have you ever been tested for H IV? (see page 81) 你有没有做过爱滋病的检验？
‧If so, when and what were the results? 如果有，什么时候做的？结果如何？
‧If not, have you ever risked exposure to HIV? (see page 81) 如果没做过检验，那你是否曾经有过不安全（可能会感染爱滋病）的性行为？
‧Has your partner ever been tested for HIV? 你的性伴侣做过爱滋病病的检验吗？
‧If so, when and what were the results? 如果做过，什么时候做的？结果如何？
‧If not, has he ever risked exposure to HIV? 如果没做过检验，那他是否曾经有过不安全（可能会感染爱滋病）的性行为？
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个月内，是否做过任何放射线检查（包括各种X光检查，电脑断层扫描，核磁共振造影检查等）:
Test检查名称：
Date做检查日期：
Test检查名称：
Date做检查日期：
Test检查名称：
Date做检查日期：
Do you plan to take any medical tests in the near future? When? Why? 你最近有安排做任何检查吗？为什么要做？什么时候做？
Please list any vaccinations you’ve had in the past 6 months: 过去6个月内，是否曾经接受疫苗注射？
Vac.疫苗名称：
Date接种日期：
Vac.疫苗名称：
Date接种日期：
Vac.疫苗名称：
Date接种日期：
Do you plan to have any vaccinations in the near future? When? Why? 你计划最近接受疫苗注射吗？什么时候？为什么？
Please list any questions or concerns you have about your current or future pregnancy:
关于你这次怀孕的疑问与疑虑，或者你担心将来再次怀孕时，可能会产生的问题或者担心，全部写下来。
摘自：《怀孕40周全书》新手父母出版＠(//www.dajiyuan.com)
