MFM Intake Questionnaire Form

MFM Intake Form

For a physical copy of our maternal fetal medicine questionnaire form, please download from the button below.

To complete the digital copy of the maternal fetal medicine form, fill the available fields on the form below.

MFM Intake Questionnaire

Intake Questionnaire

Patient's Full Name: *

Age: *

Date of Birth: *

1st day of last menstrual period: *

Established Due Date: *

Height: *

Pre-Pregnancy Weight: *

Father of this Baby (skip if sperm donor or unknown): *

Age of Biological Father: *

Pregnancy History

Total number of pregnancies (including current if pregnant): *

Term deliveries: *

Preterm deliveries (<37 weeks): *

Miscarriages/abortions/ectopics: *

Number of cesarean births: *

IVF or Fertility treatments with this pregnancy? *

Yes No

Donor Egg? *

Yes No

Age of Egg Donor: *

Donor Sperm? *

Yes No

If Yes-Are you a surrogate? *

Yes No

Donor Embryo? *

Yes No

Diagnosed with COVID-19 this pregnancy? *

Yes No

Date Diagnosed:

Have you ever received a COVID-19 vaccine? *

Yes No

Allergies:

Medications/Supplements:

Dose & How Often:

Currently Taking?

Yes No

Medications/Supplements:

Dose & How Often:

Currently Taking?

Yes No

Medications/Supplements:

Dose & How Often:

Currently Taking?

Yes No

Medications/Supplements:

Dose & How Often:

Currently Taking?

Yes No

Medications/Supplements:

Dose & How Often:

Currently Taking?

Yes No

Medications/Supplements:

Dose & How Often:

Currently Taking?

Yes No

Medical Conditions:

Do you, the father of this baby, or any close relatives have:

Thalassemia *

Yes No

Neural tube defect (meningomyelocele, spina bifida, or anencephaly) *

Yes No

Congenital heart defect (heart abnormality at birth) *

Yes No

Down Syndrome *

Yes No

Tay-Sachs *

Yes No

Canavan Disease (Ashkenazi Jewish) *

Yes No

Familial Dysautonomia (Ashkenazi Jewish) *

Yes No

Sickle Cell Disease or trait *

Yes No

Hemophilia or other blood disorders *

Yes No

Muscular Dystrophy *

Yes No

Cystic Fibrosis *

Yes No

Huntington Chorea *

Yes No

Intellectual disability/developmental delay *

Yes No

Other inherited genetic or chromosomal disorders *

Yes No

Maternal metabolic disorder (eg. Diabetes, PKU) *

Yes No

Patient or baby’s father had a child with birth defects not listed above *

Yes No

Recurrent pregnancy loss or a stillborn *

Yes No

Medications *

Yes No

Are you and the father of this baby blood relatives (i.e. cousins)? *

Yes No

Any other complications?

Consent for storing submitted data *

Yes, I give permission to store and process my data No, I don't consent to storing and processing my data

Important Visitor Update

Directory

Administration

Admissions

Billing

Concierge

Credentialing / Medical Staff Office

Dietary / Cafeteria

Education

Endoscopy

Higher Grounds Coffee

Housekeeping

Human Resources

Imaging

Infusions Therapy Services

Lab

Maintenance

Marketing

Medical Admitting

Medical Records

MedSurg

NICU

Occupational Health

PACU

Patient Financial Counselors

Pharmacy

Physical Therapy

Physicians Relations (Cherie Webster)

PreOp

Pulmonary Function Lab

Quality Assurance

Redicare

Respiratory Therapy

Sleep Lab

Speech Therapy Idaho Falls

Speech Therapy Rigby

Surgery

Surgical Scheduling

Wound Care

Women's Services (Labor & Delivery)

Urgent Surgical Scheduling

MFM Intake Questionnaire Form

MFM Intake Form