Patient Form

Patient ID

Last name *

First name *

Date of birth *

Country *

Email address *

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

Have you had any previous pregnancies?

Yes

No

For previous pregnancies, did any of the following occur? (Please indicate the number for each, if applicable)

Miscarriage

Elective termination of pregnancy

Medical termination of pregnancy

Stillbirth

Baby born with birth defect

If you feel comfortable, please describe any family history of congenital malformations or other significant health problems:

Medical history

Please specify if you have had any 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.