Locate us677 Cathedral Dr.
Rapid City, SD
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Main Clinic 605-343-9224
Appointments 605-342-6905

 
 

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 Black Hills OBGYN Patient Portal

 



 

New OB Patient

To print and complete, click here to download.

 

*Indicates required field
 

Name* Date of Birth*
Email*
 

The email you have listed will be the same email that you would use for the patient portal.
Address*
City State Zip
Phone*

Alternate

Insurance Company*
If Medicaid, who is listed as your managing primary care provider?

OBSTETRICIAN: please check who you are currently scheduled with for your pregnancy*



If you have transferred your care to BH/OB GYN, what was the date of your first prenatal visit for this pregnancy?  
Reason for transfer:
Language:     Other:

Special needs:
Current Medications: None
Please list current medications:
Medication Allergies:  
Who may we contact in the case of an emergency?*  
Relation to you* Phone*

Relationship Status:
Father of the Baby's name:*
Is the Father of the baby planning to be involved with your pregnancy?
Is he supportive of the pregnancy?
Do you have any safety concerns for you or your baby?
If Yes, please explain:
Current or most recent occupation:
Check all that apply: Homemaker Student
What have you used in the past for contraception? Check all that apply:*
Paraguard Intrauterine Device (IUD)
Mirena Intrauterine Device Natural Family Planning Diaphragm Spermicides None
Date you stopped using contraception:

PREGNANCY NOTES:
When was the first day of your last menstrual period?* Unknown  
Your age at the time of your very first period
(onset of menses)*
Periods are Regular
How often do they occur?* (days)
How long do your periods last?* (days)
Have you ever had any menstrual problems? Yes
Date of positive pregnancy test: Unknown
Please specify type of test* Urine/Home Pregnancy Test
What was your pre-pregnancy weight?*
What is your height*

Symptoms since your last menstrual period, check all that apply:*
Vaginal Bleeding   Abdominal pain   Headaches   Dizziness
Changes in vision   Nausea   Vomiting   Difficulty keeping down oral fluids for 24 hours or more  
Lack of appetite   Pain with urination   Back pain   Fever   Constipation
Have you had any Emergency Room visits during this pregnancy?* Yes, date No
Reason:
Details on the symptoms that warranted your ER visit or other symptoms you would like us to be aware of?
Do you have a history of infertility?* Yes
If yes, what treatment have you undergone

GYN HISTORY:
Polycystic Ovarian Syndrome (PCOS)  Fibroids  Endometriosis  Pelvic Pain   Infertility  
Heavy Periods   Painful Periods   Bleeding Between Periods   Sexual abuse/assault  
Uterine abnormalities  
Comments:
Date of last Pap Smear Unknown  I have never had a pap smear
Results:* Normal  Abnormal  I have never had a pap smear
Abnormal pap smear follow up:*
No history of an abnormal pap smear  Repeat Pap Smear  Colposcopy  Cryotherapy  
Loop Electrode Excision Procedure (LEEP)  

FAMILY OBSTETRICAL HISTORY:
Your Birth Weight lb.   oz.
Father's Birth Weight lb.   oz.
Any family history of trauma associated with childbirth in your immediate family   Yes  No


PREGNANCY SUMMARY:*
Total number of pregnancies Number of Full Term Deliveries
Number of Preterm Deliveries Number of miscarriages
Number of Abortions Number of Vaginal Deliveries
Number of C-Section Deliveries Number of Children Living

PREGNANCY NOTES/HISTORY:* : list all delivery dates, please include any miscarriages or abortions
Delivery Date Sex of Baby Weight Gestation
age, weeks
Hours in Labor Type of Delivery Anestesia Place of Delivery Comments/
Complications

Do you have any religious or cultural beliefs that may affect your obstetrical care? Check all that apply
No Restrictions  Decline blood products and/or blood transfusions  Decline vaccinations  
Other  


For past pregnancies, have you been diagnosed with any of the following? Check all that apply
Anemia   Gestational Diabetes   Intrauterine Growth Restriction (IUGR)   Incompetent Cervix
High Blood Pressure in Pregnancy   Post Partum Depression   Uterine/Placental Infection
Too much amniotic fluid (Polyhydramnios)   Too little amniotic fluid (Oligohydramnios)
Previous C-Section Delivery   Stillbirth   Uncomplicated Past Pregnancy(s)  

PERSONAL MEDICAL HISTORY:*

Seasonal Allergies: None  Yes, please list:
Anemia/Blood Disorder: No  Yes, date/comments:
Asthma/Lung Disorders: No  Yes, date/comments:
Autoimmune Disorder: No  Yes, please list:
Blood Transfusion: No  Yes, please list:
Breast Disorders: No  Yes, please list:
Depression: No  Yes, date/comments:
Anxiety/Psychiatric Disorder: No  Yes, date/comments:
Type I Diabetes: No  Yes, date/insulin
                 type/dose, etc.:
Type 2 Diabetes: No  Yes, date/treatment:
High Blood Pressure: No  Yes, date/comments:
Heart Disease: No  Yes, date/comments:
Liver Disease: No  Yes, date/comments:
Neurological Disorders
(i.e. strokes, seizures, migraines)
No  Yes, date/comments:
Kidney Disease: No  Yes, date/comments:
What is your blood type? Unknown O A B AB –Positive Negative Unknown
Have you ever received
Rhogam in the past?
No  Yes
If you have a negative blood type,
have you ever been informed that
you are Rh Sensitized?
No  Yes  Unknown  I do not have a negative blood type
Thyroid Disorder: No  Yes, date/comments:
History of physical trauma (i.e.
physical abuse, motor vehicle
accident, etc):
No  Yes, date/comments:
Have you ever had complications
with anesthesia?
No  Yes, date/comments:
Cancer: No  Yes, date/comments:
Gastrointestinal Problems: No  Yes, date/comments:
Musculoskeletal Problems: No  Yes, date/comments:


SUBSTANCE USE:*
Smoking Tobacco: No  Yes       Quit Date:
          Prior to pregnancy I smoked cigs/day     I currently smoke cigs/day    
Chewing Tobacco: No  Yes       Quit Date:
          Prior to pregnancy I chewed cans/day     I currently chew cans/day    
Alcohol Use: No  Yes  
          Prior to pregnancy I drank drinks/day     I currently drink drinks/day    
Illicit Drug : No  Yes       What type:
          Prior to pregnancy I used times/day     I currently use times/day    
          Quit Date
Do you have any concerns about substance use or would like information on how to quit? No  Yes, explain:


LIST ANY SURGICAL PROCEDURES YOU HAVE HAD DONE:*
SurgeryDate
Have you ever been admitted to the hospital for any reason?
No  Childbirth Only  Yes, explain:


IMMEDIATE FAMILY HISTORY:* (Parents, Siblings, Grandparents)
Please specify if person(s) is on maternal or paternal side of your family. Include age of diagnosis if known.
Heart Disease: No  Yes,    List:
Heart Attack: No  Yes,    List:
High Blood Pressure No  Yes,    List:
Thyroid Disorder No  Yes,    List:
Autoimmune Disorder No  Yes,    List:
Tuberculosis No  Yes,    List:
Diabetes No  Yes,    List:
Chronic Renal Disease No  Yes,    List:
Cancer No  Yes,    List:
Stroke No  Yes,    List:
Seizure Disorder No  Yes,    List:
Psychiatric/Mental Health Disorder No  Yes,    List:
Other      Please describe:
Family History Knowledge Limited/Unknown No  Yes,    Comments:


GENETIC SCREENING:*
these questions are for you, the father of the baby and both your immediate family members to the best of your knowledge. If unknown, check ‘No’. (Patient = Your personal history)
Your Current Age   Father of the Baby's Current Age
Neural Tube Defects (spina bifida/anacephaly) No History  Patient  Father of the baby
    Family Member(s):
Down Syndrome No History  Patient  Father of the baby
    Family Member(s):
Congenital Heart Defect No History  Patient  Father of the baby
    Family Member(s):
Cystic Fibrosis No History  Patient  Father of the baby
    Family Member(s):
Tay-Sachs, Thalassemia No History  Patient  Father of the baby
    Family Member(s):
Canavan Syndrome No History  Patient  Father of the baby
    Family Member(s):
Autism No History  Patient  Father of the baby
    Family Member(s):
    If yes, has the person(s) diagnosed with
         Autism been tested for Fragile X?
No  Yes  Unknown
Mental Retardation No History  Patient  Father of the baby
    Family Member(s):
Muscular Dystrophy No History  Patient  Father of the baby
    Family Member(s):
Sickle Cell Disease No History  Patient  Father of the baby
    Family Member(s):
Cleft Lip/Cleft Palate No History  Patient  Father of the baby
    Family Member(s):
Other Inherited Genetic Disorder or Birth Defects No History  Patient  Father of the baby
    Family Member(s):
          If yes, explain:
Maternal Metabolic Disorder (i.e. PKU, Diabetes) No History  Patient  Father of the baby
    Family Member(s):
Recurrent Pregnancy Loss or Stillbirth No History  Patient  Father of the baby
    Family Member(s):
Father of the Baby’s Personal/Family History is unknown Father's History is unknown
Are you interested in having chromosomal blood testing (i.e. Harmony Prenatal Test/Quad Screen) during this pregnancy? No  Yes  I would like to discuss further at my appointment

EXPOSURE/INFECTION HISTORY* (Patient = Your Personal History)
HIV No History  Patient  Father of the baby/Current Sexual Partner
Genital Herpes No History  Patient  Father of the baby/Current Sexual Partner
    If yes, date of last
    outbreak/Comments:
Gonorrhea No History  Patient  Father of the baby/Current Sexual Partner
    If yes,date/Comments:
Chlamydia No History  Patient  Father of the baby/Current Sexual Partner
    If yes,date/Comments:
HPV No History  Patient  Father of the baby/Current Sexual Partner
    If yes,date/Comments:
Syphilis No History  Patient  Father of the baby/Current Sexual Partner
    If yes,date/Comments:
Genital Warts No History  Patient  Father of the baby/Current Sexual Partner
    If yes,date/Comments:
Hepatitis No History  Patient  Father of the baby/Current Sexual Partner
    If yes,date/Comments:
Have you had a rash or viral
illness since your last menstrual period?
No  Yes
    If yes,location/treatment:
Do you have a history of chickenpox or
were you vaccinated for chickenpox
(varicella) as a child?
No  Yes
Have you had any exposures to a viral illness, radiation, X-rays, toxoplasmosis (cat litter boxes), Fifth’s Disease, or cytomegalovirus (CMV) since your last menstrual period?
   No  Yes, please specify:
Do you have any cats in the home? No  Yes
   If yes, pregnant women should not change the litter box due to the risk of toxoplasmosis which is a parasite in cat
   feces. Who changes the litter box in your home?
Have you ever been diagnosed with Methicillin Resistant Staph Aureus Infection (MRSA)?
   No  Yes, date/Comments:
Date of last Flu Vaccine
   Unknown  Date:
Date of last Tetanus Diphtheria Pertussis (Whooping Cough) Vaccine
   Unknown  Date:

DELIVERY PLAN
 
Delivery Plan:
Vaginal Delivery  Repeat Cesarean Section  Trial of Labor after Cesarean Section Delivery
Feeding Method: Breastfeed  Bottle feed  Breastfeed and Bottle  Undecided
Are you planning an epidural for pain relief in labor? Yes  No  Undecided
If you have a baby boy, do you plan on having him circumcised?Yes  No  Undecided
Are you planning permanent sterilization after this pregnancy?Yes  No  Undecided
Do you have other plans for birth control after this pregnancy?
No, thank you  Natural Family Planning  Mirena IUD  Paraguard IUD  Nexplanon
Birth Control Pills  Condoms  Diaphragm  Spermicides  Same Sex Relationship
I would like to discuss my options with my provider

PEDIATRICIAN CHOICE — all babies will be seen by the pediatrician on call through Black Hills Pediatrics during their hospital stay. Upon discharge I plan to have my baby(s) follow up with:
Continue Care with pediatrician who is on call when I deliver
Black Hills Pediatrics/Choice of Provider at this facility:
Current Pediatrician/Family Practice Provider:
Provider/Pediatrician at Ellsworth Airforce Base
Undecided
 
Other pregnancy info you would like us aware of (i.e. currently breastfeeding another child, planning to move to another location during this pregnancy, surrogacy pregnancy, pregnancy conceived with sperm donor, etc.):

Thank you and congratulations on your pregnancy! If we have any questions, we will contact you by phone prior to your appointment. Return calls from Black Hills OB/GYN may show up as “unknown” or “restricted” for some phone carrier services. If you have voice-mail capabilities on your phone, please have it set up so we may leave a message if you are unable to answer at the time of our call. If you have any questions or concerns that you feel need addressed before your scheduled appointment, please contact us at 605-343-9224. We look forward to seeing you!

- The Staff at Black Hills Obstetrics and Gynecology