Dr. Hazay Máté szülészeti-nőgyógyászati magánrendelés

Pregnant patients - health history questionnaire

Dear Expectant Mother,

At the first visit, before examining the Baby, we will discuss your health parameters in detail, and review the relevant previous medical findings and the results obtained during pregnancy (blood test, ultrasound, tests, etc.)

You can help this process by filling out the questionnaire below.

(All data filling is considered confidential health information and is treated as a medical secret)

Thank you for your cooperation, I look forward to seeing you (and your dear partner) on your first visit!

Name (monogram is sufficient)

When was the first day of your last period?

History of previous births:

Birth year of 1st child

Pregnancy weeks

Birth weight (g)

Were there any complications?

Mode of delivery

History of previous births - second child

Birth year of 2nd child

Pregnancy weeks

Birth weight (g)

Were there any complications?

Mode of birth

History of previous births - third child

Birth year of 3rd child

Pregnancy weeks

Birth weight (g)

Were there any complications?

Mode of delivery

History of previous births - fourth child

Birth year of 4th child

Pregnancy weeks

Birth weight (g)

Were there any complications?

Mode of delivery

Have you had a miscarriage before 12 weeks?

Have you had a miscarriage between the 12-24th weeks?

Do you have any illness? (diabetes, hypertension, thyroid malfunction, etc.)

Have you had any surgery?

Do you take any medication?

Do you have any drug allergies?

Have you received blood or blood products before?

Has there been a genetic disease, thrombosis, or heart development disorder in your or your partner's family?

Your age

When was the last cancer screening (cytology) done? What was the result?

Is there anything else important? (even a question)

Sending previous medical data of your pregnancy (laboratory tests, ultrasound findings, etc.)

If you agree, I can access your previous hungarian medical records via the EESZT system, by entering yor Social Security number (TAJ-number) and date of birth (recommended)

TAJ-szám

Your date of borth

Day

Month

Year

I agree that Dr. Máté Hazay can view my previous findings through EESZT system

(If you do not agree or do not have a TAJ number, please send your findings by email to info@drhazaymate.hu)