Health Care Provider Form

Patient ID

Last name *

First name *

Date of birth *

Country *

Weight

kg

or

st

lb

Height

cm

or

ft

in

Pregnancy confirmation date

Pregnancy dating at the time of diagnosis
(gestational age - in weeks)

weeks

Method of pregnancy diagnosis

Ultrasound

Home pregnancy test

Serum pregnancy test

Date of last menstrual period (first day of last menstrual period)

Maternal history

Any previous pregnancy?

Yes

No

Previous pregnancy outcomes: (Indicate the number for each, if applicable)

Spontaneous abortion

Elective termination

Therapeutic abortion

Foetal death

Birth defect

Please describe any maternal family history of congenital anomaly or any other significant family conditions:

Medical history

Significant medical condition (e.g. diabetes, hypertension, ...) before and/or during pregnancy, including start date and stop date/ongoing at the time of pregnancy outcome