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

history of bleeding disorder - Select -yesno

history of diabetes - Select -yesno

history of hypertension - Select -yesno

history of lupus - Select -yesno

history of thyroid disease - Select -yesno

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

if yes, please list

list OB/GYN(s)

where do you plan to deliver your baby

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