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Register with Ombudu
This is your personal pre-natal and medical history.
It will be available at anytime for you and your providers.
Select a user name (we suggest your first name) and
password.
Your password should be at least 6 characters with numbers
and letters. It is not case sensitive.
Demographic Information
User Name:
Password:
Birth Date:
Age:
Where do you get your care?:
Who is your Healthcare Provider?:
Provider Title:
Emergency Contact:
Contact Phone:
Ethnicity:
Your Medical History-Current Pregnancy
Pregnancy Number:
Full Term:
Pre Term:
Abortions/Miscarriages:
Living Children:
Have you had a Cesarean C-section?
Yes
No
If yes, why?
LMP:
EDD:
Allergies (List all separated by 'comma'):
Medications (List all separated by 'comma'):
Gestational Diabetes?
Yes
No
Pre Gestational Diabetes?
Yes
No
Chronic Hypertension?
Yes
No
Pre Eclampsia?
Yes
No
Cardiac Disease?
Yes
No
Asthma?
Yes
No
Thyroid Disease?
Yes
No
Blood Clotting Problems?
Yes
No
Tuberculosis?
Yes
No
Active Hepatitis B?
Yes
No
Active Hepatitis C?
Yes
No
Sexually Transmitted Infections?
Yes
No
Abnormal Bleeding?
Yes
No
Known Fetal Anomaly?
Yes
No
Other Information /Explain (List all separated by 'comma'):
Past Pregnancy, Medical and Surgical History
Gestational Diabetes?
Yes
No
Pre Gestational Diabetes?
Yes
No
Chronic Hypertension?
Yes
No
Pre Eclampsia?
Yes
No
Cardiac Disease?
Yes
No
Asthma?
Yes
No
Thyroid Disease?
Yes
No
Blood Clotting Problems?
Yes
No
Tuberculosis?
Yes
No
Active Hepatitis B?
Yes
No
Active Hepatitis C?
Yes
No
Abnormal Bleeding?
Yes
No
Fetal Anomaly?
Yes
No
Other Information /Explain (List all other conditions, surgeries,
medical or current pregnancy related disorders separated by 'comma'):
Genetics, Birth Defects and Infection Questions
Do you or the father of your baby have a history of:
Thalassemia or Mediterranean Anemia ?
Yes
No
Neural Tube Defect-Spina Bifidia?
Yes
No
Congenital Heart Disease?
Yes
No
Down Syndrome?
Yes
No
Sickle Cell Disease or Carrier?
Yes
No
Hemophilia?
Yes
No
Muscular Dystropy?
Yes
No
Cystic Fibrosis?
Yes
No
Mental Retardation?
Yes
No
Other Birth Defects?
Yes
No
Smoke Tobacco?
Yes
No
Routinely Drink Alcohol?
Yes
No
Use of 'Street Drugs?
Yes
No
Herpes Infections?
Yes
No
Gonorhea?
Yes
No
Chlamydia?
Yes
No
Syphillis?
Yes
No
HPV?
Yes
No
HIV?
Yes
No
Other Information /Explain (List all other past conditions, surgeries,
medical or past pregnancy related disorders separated by 'comma'):
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