Y-M-D       Yes       No Primary Tel: home cel work Alt Tel: home cel work Interpreter required? No Yes → language required IVF Pregnancy? No Yes → was ICSI used? Yes No

Patient’s Current Weight: LB KG
Smoking in pregnancy? Never Yes→current/quit

Diabetes in pregnancy? No Type 1 Type 2 Gestational Antenatal Records Yes No

Blood Type           Yes No
Hematology           Yes No

Thalassemia           Yes No

Virology (rubella) Yes No

Cervical swabs       Yes No
MRSA Positive      Yes No
Yes No
Declined NIPT: Yes No Declined

Amnio: Yes No Declined Ultrasound: Yes No Booked
           when & where?