[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-357657-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-357657-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","obgyn-care-visit-new-ob-questionnaire","OB/GYN Care Visit - New OB Questionnaire","","OB/GYN Care Visit worksheet for collecting comprehensive prenatal intake information to support pregnancy care planning. Captures personal demographics, father of baby details, and key reproductive history. Includes last menstrual period specifics, symptom screening since the last menstrual period, and questions about contraception, breastfeeding, vaccinations, and infectious disease testing objections. Also gathers detailed pregnancy history for each prior pregnancy, including dates, gestational age, delivery course, anesthesia, complications, and neonatal outcomes.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/obgyn-care-visit-new-ob-questionnaire/357657/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/obgyn-care-visit-new-ob-questionnaire/357657.png","ImageObject",442,249,{"name":42,"@type":43},"Aria","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-23",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",8,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does the OB/GYN Care Visit worksheet collect first?","Question",{"text":63,"@type":64},"It collects personal demographics and basic details, including the patient’s name and occupation, marital status, household members, religion, spoken language, and ethnic background.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What does the worksheet ask about the last menstrual period?",{"text":68,"@type":64},"It asks whether the patient knows the start day, confirms the date, checks whether the last period was normal, and collects information about cycle regularity and related timing.",{"name":70,"@type":61,"acceptedAnswer":71},"What does the pregnancy history section include for prior pregnancies?",{"text":72,"@type":64},"For each pregnancy, it requests birth or end date, gestational weeks, infant name and weight, labor duration, delivery location and provider, anesthesia details, delivery method checkboxes, neonatal Apgar scores, complications, and whether delivery was full term or premature.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},357657,1791334355,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":136,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":12,"update_tm":141,"read_time":30},2336464648322,"https://ap-avatar.wpscdn.com/avatar/2200025388227c56fec?_k=1778556882303663488","OB/GYN Care Visit  \nThis worksheet is used to help you and your health care provider determine your pregnancy care needs. We will use this form to enter information into Kaiser Permanente's secure medical record system.  \nKaiser Permanente values your privacy. Your answers will be kept confidential.  \n\n| Personal Information | CLINIC USE ONLY |\n| --- | --- |\n| Your name: | In Epic: Patient Demographic Information |\n| Occupation: |  |\n| Are you married? 􀂈 Yes 􀂈 No |  |\n| Are other people living with you? 􀂈 Yes 􀂈 No\u003Cbr>If yes , who lives with you: |  |\n| Religion: |  |\n| Language spoken:\u003Cbr>If you need an interpreter, in what language? |  |\n| Ethnic background: |  |\n| Father of Baby | CLINIC USE ONLY |\n| Name: | In Epic: Father of Baby |\n| Age: |  |\n| Occupation: |  |\n| Ethnic background: |  |\n| Religion: |  |\n| Home phone number: |  |\n| Work phone number: |  |\n| Cell phone number: |  |\n| Have you ever had genetic testing? 􀂈 Yes 􀂈 No\u003Cbr>If yes , what were you tested for: |  |\n\nNOT TO BE FILED IN THE MEDICAL RECORD  \n\n| Last Menstrual Period Information | CLINIC USE ONLY |\n| --- | --- |\n| Do you know the day your last menstrual period started? 􀂈 Yes 􀂈 No | In Epic: New OB Questionnaire |\n| If yes , when did your last menstrual period start (month/day/year): |  |\n| Are you sure of this date? 􀂈 Yes 􀂈 No |  |\n| Was your last period normal? 􀂈 Yes 􀂈 No |  |\n| If your periods are not regular:\u003Cbr>What is the shortest time (in days) from one period to the next?   What is the longest time (in days) from one period to the next?   |  |\n| How many days from the beginning of\u003Cbr>one period to the beginning of the next? |  |\n| Symptoms since last menstrual period\u003Cbr>Do you currently have any of the following symptoms:\u003Cbr>􀂈 abdominal pain\u003Cbr>􀂈 blood in the stools or urine\u003Cbr>􀂈 chest pain\u003Cbr>􀂈 shortness of breath\u003Cbr>􀂈 coughing\u003Cbr>􀂈 vomiting\u003Cbr>􀂈 pain on urination\u003Cbr>􀂈 vaginal discharge\u003Cbr>􀂈 vaginal bleeding\u003Cbr>􀂈 nausea\u003Cbr>􀂈 headache\u003Cbr>􀂈 constipation |  |\n| Birth Control and Breastfeeding | CLINIC USE ONLY |\n| Were you taking birth control at the time of conception? 􀂈 Yes 􀂈 No | In Epic: New OB Questionnaire |\n| Did you take birth control pills before becoming pregnant? 􀂈 Yes 􀂈 No |  |\n| When did you stop taking them (month/day/year): |  |\n| Were you breastfeeding at the time of conception? 􀂈 Yes 􀂈 No |  |\n| Vaccinations and Tests | CLINIC USE ONLY |\n| Have you had chicken pox or been vaccinated against Varicella? 􀂈 Yes 􀂈 No | In Epic: New OB Questionnaire |\n| Have you ever received the Hepatitis B vaccine? 􀂈 Yes 􀂈 No |  |\n| When did you receive your last tetanus vaccine (Tdap): |  |\n| We will test you for Hepatitis B. Do you object to this? 􀂈 Yes 􀂈 No |  |\n| We will test you for HIV. Do you object to this? 􀂈 Yes 􀂈 No |  |\n\nNOT TO BE FILED IN THE MEDICAL RECORD  \n\n| Pregnancy History | CLINIC USE ONLY |\n| --- | --- |\n| Please answer the following questions for each pregnancy you’ve had. If you’ve never been pregnant, please skip to the next section. | In Epic:\u003Cbr>OB History |\n| How many pregnancies have you had? |  |\n| Date of birth or end of pregnancy: |  |\n| How many weeks? |  |\n| What is the baby’s name? |  |\n| How much did the baby weigh? |  |\n| Do you know what the baby’s one and five minute Apgars were? Apgar 1-minute:\u003Cbr>Apgar 5-minute: |  |\n| How long were you in labor? |  |\n| Where was the baby delivered? |  |\n| What was the name of your pregnancy care provider? |  |\n| Did you have anesthetic? 􀂈 Yes 􀂈 No\u003Cbr>If yes, what kind? 􀂈 Subarachnoid block 􀂈 IV Analgesic 􀂈 Local\u003Cbr>􀂈 Spinal 􀂈 General 􀂈 Epidural 􀂈 Pudendal |  |\n| If you’ve had a baby, please check the following for your birth:\u003Cbr>􀂈 Vaginal delivery 􀂈 Pregnancy termination (abortion)\u003Cbr>􀂈 Cesarean section 􀂈 Ectopic (tubal) pregnancy\u003Cbr>􀂈 Help of a vacuum extractor 􀂈 Stillbirth\u003Cbr>􀂈 Help of forceps 􀂈 Miscarriage\u003Cbr>􀂈 Breech birth\u003Cbr>􀂈 Multiple babies (ie: twins, triplets) |  |\n| What was the sex of the baby? 􀂈 Male 􀂈 Female 􀂈 Unknown 􀂈 Other |  |\n| Is this child still living? 􀂈 Yes 􀂈","cbCaich0vTWf9UZW","https://ap.wps.com/l/cbCaich0vTWf9UZW","pdf",161735,7,"English","# Personal Information\n# Father of Baby\n# Last Menstrual Period Information\n# Symptoms Since Last Menstrual Period\n# Birth Control and Breastfeeding\n# Vaccinations and Tests\n# Pregnancy History\n## Second pregnancy (if applicable)\n## Third pregnancy (if applicable)","[{\"question\":\"What information does the OB/GYN Care Visit worksheet collect first?\",\"answer\":\"It collects personal demographics and basic details, including the patient’s name and occupation, marital status, household members, religion, spoken language, and ethnic background.\"},{\"question\":\"What does the worksheet ask about the last menstrual period?\",\"answer\":\"It asks whether the patient knows the start day, confirms the date, checks whether the last period was normal, and collects information about cycle regularity and related timing.\"},{\"question\":\"What does the pregnancy history section include for prior pregnancies?\",\"answer\":\"For each pregnancy, it requests birth or end date, gestational weeks, infant name and weight, labor duration, delivery location and provider, anesthesia details, delivery method checkboxes, neonatal Apgar scores, complications, and whether delivery was full term or premature.\"}]","OB/GYN Care Visit - New OB Questionnaire | PDF",1790131104]