Pregnancy Par - Q

First Name

Last name

Due Date

With this current pregnancy are you experiencing any of the following?

Have you experienced any past miscarriages or pregnancy complications?

Yes

No

Marked fatigue

Spotting

Fainting or Dizziness

Sudden swelling of ankles or face.

Headaches

Pregnancy induced hypertension or pre-eclampsia

Swelling, pain or redness in the calf of one leg

Failure to gain weight after 5th month

Premature labour or ruptured membranes

Evidence of intrauterine growth restriction

Incompetent cervix ___

High risk pregnancy

Anemia

Multiples

Please share any other important information regarding your health and this pregnancy.

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