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General

Health

Do you smoke:
Do you drink alchohol:
Ever used drugs:
Do you sometimes have cold sores?:
Have you ever been treated for STIs:
Do you use medicines?:
Do you have allergies:
Have you ever been severly ill:
Did you ever had surgery:
Did you ever had a blood transfusion:

Health partner

Does your partner smoke:
Does your partner sometimes have cold sores:
Is your partner healthy:

Family history woman

Are there any genetic anormalities in the family (like down Syndrome):
Is there family with a high blood pressure:
Is there diabetes present in your family:
Are there twins in the family:
Does anyone in the family ever had tuberculosis:

Family history partner

Are the any genetic abnormalities in the partners family:
Does any of the family of the partner have high blood pressure:
Is diabetes present in the partners family?:
Are there any twins in your partners family:
Is there anyone in your partners family who ever had tuberculosis:

Previous Pregnancies

Current Pregnancy