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GESTATIONAL DIABETES
History & Assessment
Diabetes History Primary Care Provider __________________________
Do you have a family history of diabetes? Yes No If yes, who and what type __________
Do you have a previous history of gestational diabetes? Yes No
Did you have diabetes prior to pregnancy? Yes No
If yes, for how long? _____________________ Type of diabetes? _________________________
If you had diabetes prior to this pregnancy, did you receive preconception care and/or instruction
regarding diabetes and pregnancy? Yes No
Pregnancy History
How many weeks pregnant are you today? ________When is your expected due date?________
How much did your babies weigh? ___________ Any premature babies? ____________________
Medical History
Check if you have any of the following medical conditions:
High blood pressure High cholesterol Depression
Please list other medical conditions you have: _____________________________________
Height_____________ Current Weight _____________ Pre-pregnancy weight _____________
Preconception A1C _____________ Date: _____________________
Exercise Profile
Do you exercise? Yes No If yes, what do you do? _____________________________
How often? _______________ If no, list reason or problems that prevent you from exercising:
____________________________________________________________________________
Smoking/Alcohol History
Do you smoke? Yes No If yes, how much? _______________________________________
Did you ever smoke? Yes No If yes, when did you stop? ___________________________
Do you drink alcohol? Yes No If yes, how much? _________________________________