fetal echocardiogram intake form date of study patient name patient date of birth estimated due date total number of pregnancies (including current pregrancy) number of full term number of premature number of miscarriages history of asthma - Select -yesno - Select - history of bleeding disorder - Select -yesno - Select - history of diabetes - Select -yesno - Select - history of hypertension - Select -yesno - Select - history of lupus - Select -yesno - Select - history of thyroid disease - Select -yesno - Select - list any medication you have taken during this pregnancy please list other conditions do you have a family history of congenital heart disease or have you had a previous child with a congenital heart issue - Select -yesno - Select - if yes, please list list OB/GYN(s) where do you plan to deliver your baby CAPTCHA
