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Get Western OB/GYN Prenatal Medical History Form

Ds last: __________ Date of last pap smear: __________ Normal: Y N Date of 1st positive pregnancy test: ________________________ Current medications: ___________________________________________________________________ Allergies: ______________________________ Date of Tdap immunization(Tetanus with Pertussis)______ Previous Pregnancy History Total # preg (including this one) _____ Full term _____Premature (<37 wk) _____ Termination_____ Miscarriage _____ Ectopic (tubal preg) _____ Multiple births.

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