Bahasa Malaysia

NAME :

AGE :

No. OF CHILDREN:

                                                                                     DATE: 

                                                                                     DATE LAST PERIOD :
                                                                                     (1ST DAY)

                                                                                     DUE DATE:

PLEASE TICK IF RELEVANT TO YOU

CURRENT PREGNANCY

1. IVF pregnancy
2. IUI pregnancy
3. Bleeding in pregnancy
4. Diabetes
5. High BMI
6. ​Body itching

PAST PREGNANCY

1. hypertension in pregnancy
2. intrauterine growth restriction (< 2.5 kg)
3. preterm birth (< 37 weeks)
4. baby with newborn infection
5. baby with physical deformity
6. baby with mental deficiency
7. baby with genetic abnormality
8. miscarriage
9. stillbirth

MEDICAL

1. Thalassemia
2. Diabetes
3. Epilepsy
4. Other Medical conditions: 
5. Current Medications: 
6. Supplements:
7. Allergies:
8. Operations: 
9. Thrombosis

HABITS

1. Smoking
2. Alcohol consumption
3. Pets at home: a. cats     b. dogs.   c. birds/poultry d. others

FAMILY WITH:

1. Diabetes
2. Born with Heart disease
3. Mental deficiency
4. born with external or internal defects
5. Thalassemia
6. Sister with hypertension in pregnancy
7. Down Syndrome
8. Any Genetic disorder
9. Stillbirth
10. Repeated miscarriage
11. Sudden death at young age
    

Issues to discuss with doctor:
1.
2.
3.
​

ALL THE ABOVE CARY SPESIFIC RISK FACTOR FOR THE CURRENT OR FUTURE PREGNANCY
​THIS WILL BE DISCUSSED BY THE DOCTOR

​Print this Form And Bring iot to the Appointment