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ROUTINE ANATOMY SCAN MEDICAL HISTORY FORM Name DOB Please check the following pertinent information o Antiphospholipid Antibody OBGYN HISTORY o abnormal Pap Syndrome o LEEP o Asthma o Cone biopsy o Seizure disorder o Miscarriage o Other please specify o Preterm Delivery FAMILY HISTORY o Preterm Labor o Mental Retardation o Full Term Delivery o Chromosomal Abnormality o Prior Cesarean Section o Congenital Heart Defect o Gestational Diabetes in Prior o Neural Tube Defect Pregnancy o Other Genetic Disorder o Stillbirth please specify o Intrauterine Death 22 weeks CURRENT PREGNANCY o Recurrent Abortion o Bleeding/Spotting 1st Trimester 640. 03 MEDICAL HISTORY o Other Cardiac Disease trimester 641. 93 o Renal Disease o Had a Subchorionic o Hypertension Hematoma 656. 83 o Pre-Gestational Diabetes o Cervical Shortening 647. 73 o Cerclage 654. 53 o Liver Disease o Abdominal Cramping 789. 00 o Hypothyroid o Abnormal 1st or 2nd Trimester Down syndrome Screen o Autoimmune Disorder please o Had CVS or Amniocentesis specify this Pregnancy 659. 63 o Deep Vein Thrombosis/Pulmonary o Fibroid Uterus 654. 13 Embolus o Lupus 710. 1 o Crohn s Disease 555. 9 LIST ANY OTHER RELEVANT INFORMATION Please Sign Below I understand an ultrasound examination cannot rule out all anatomic abnormalities or genetic syndromes Signature Date. 03 MEDICAL HISTORY o Other Cardiac Disease trimester 641. 93 o Renal Disease o Had a Subchorionic o Hypertension Hematoma 656. 83 o Pre-Gestational Diabetes o Cervical Shortening 647. 73 o Cerclage 654. 53 o Liver Disease o Abdominal Cramping 789. 83 o Pre-Gestational Diabetes o Cervical Shortening 647. 73 o Cerclage 654. 53 o Liver Disease o Abdominal Cramping 789. 00 o Hypothyroid o Abnormal 1st or 2nd Trimester Down syndrome Screen o Autoimmune Disorder please o Had CVS or Amniocentesis specify this Pregnancy 659. 00 o Hypothyroid o Abnormal 1st or 2nd Trimester Down syndrome Screen o Autoimmune Disorder please o Had CVS or Amniocentesis specify this Pregnancy 659. 63 o Deep Vein Thrombosis/Pulmonary o Fibroid Uterus 654. 13 Embolus o Lupus 710. 1 o Crohn s Disease 555. 63 o Deep Vein Thrombosis/Pulmonary o Fibroid Uterus 654. 13 Embolus o Lupus 710. 1 o Crohn s Disease 555. 9 LIST ANY OTHER RELEVANT INFORMATION Please Sign Below I understand an ultrasound examination cannot rule out all anatomic abnormalities or genetic syndromes Signature Date. 03 MEDICAL HISTORY o Other Cardiac Disease trimester 641. 93 o Renal Disease o Had a Subchorionic o Hypertension Hematoma 656. 83 o Pre-Gestational Diabetes o Cervical Shortening 647. 73 o Cerclage 654. 53 o Liver Disease o Abdominal Cramping 789. 00 o Hypothyroid o Abnormal 1st or 2nd Trimester Down syndrome Screen o Autoimmune Disorder please o Had CVS or Amniocentesis specify this Pregnancy 659. 83 o Pre-Gestational Diabetes o Cervical Shortening 647. 73 o Cerclage 654. 53 o Liver Disease o Abdominal Cramping 789. 00 o Hypothyroid o Abnormal 1st or 2nd Trimester Down syndrome Screen o Autoimmune Disorder please o Had CVS or Amniocentesis specify this Pregnancy 659. 63 o Deep Vein Thrombosis/Pulmonary o Fibroid Uterus 654. 13 Embolus o Lupus 710. 1 o Crohn s Disease 555.

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Keywords relevant to Anatomy Scan History Form

  • Hypothyroid
  • Cerclage
  • LEEP
  • OBGyn
  • cvs
  • Antiphospholipid
  • Fibroid
  • Hyperthyroid
  • gestational
  • Amniocentesis
  • Chromosomal
  • Anatomic
  • INTRAUTERINE
  • embolus
  • syndromes
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