HOSPITAL TRANSFER INFORMATION              BLOOD TYPE______________

Name ___________________________________Age______Birth date ____________

Address ______________________________________________________________

Home Phone __________________________________________________________

Emergency phone contact________________________________________________

Insurance ____________________________________________________________

Currently taking any medications? _________________________________________

smoke? __________ Use drugs? _______________

Overall health is thought to be (circle one) :   good      poor       excellent

Surgeries?_______________________________________________________________

Injuries? _______________________________________________________________

Accidents? _____________________________________________________________

Blood transfusions? ______________________________________________________

Allergies to any medications?_______________________________________________

Have any known STD's or vaginal infections? ___________________________________

Any complications with this pregnancy? _______________________________________

PREVIOUS LIVE BIRTHS: (list date, place, labor length, any complications) _______________

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PREVIOUS PREGNANCIES AND BIRTHS: (Any difficulties, diabetes, heavy bleeding, hemorrhage, Pre/Eclampsia, high blood pressure, or problems with the baby after birth?) _____________________________________________________________________

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FAMILY HISTORY: (Any kidney problems, congenital abnormalities, stroke, heart trouble, diabetes, high blood pressure, cancer, clots or bleeding?)______________________________________________________________________

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 OTHER: