High Risk Pregnancy Intake Form
What a high risk pregnancy intake form asks, with sample questions for maternal-fetal medicine staff.
A high risk pregnancy intake form records the referring doctor, pregnancy dates, conception method, past pregnancies, and health history before a maternal-fetal medicine visit. It's also called a perinatology consult form.
High risk pregnancy intake form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a high risk pregnancy intake form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample high risk pregnancy intake form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- What is the name of your doctor's group?Referral
- Who is your doctor for this pregnancy?Referral
- When did your last menstrual period start?This pregnancy
- What is your due date?This pregnancy
- Was this pregnancy conceived through IVF or IUI?Conception
- Was a donor egg used?Conception
- How many times have you been pregnant, including now?Past pregnancies
- Were any past deliveries by cesarean section?Past pregnancies
- Have you had any premature deliveries?Past outcomes
- Did a past pregnancy have complications or birth defects?Past outcomes
- Do you have diabetes or heart disease?Health history
- Which medicines are you currently taking?Health history
These are examples to read, not a form to fill in.
High risk pregnancy intake form: FAQ
What does a high risk pregnancy intake form ask?
The sample questions on this page are based on the maternal-fetal medicine patient questionnaire of Valley Health System in New Jersey. This page groups them into six areas: referral, this pregnancy, conception, past pregnancies, past outcomes, and health history.
Who fills in a high risk pregnancy intake form, and when?
The pregnant patient, before the first maternal-fetal medicine appointment. The Valley Health System form starts with the appointment date, height and weight, and a latex allergy check.
Does it ask how the pregnancy was conceived?
Yes. The Valley Health System form asks whether this pregnancy followed IVF, ICSI, PGD, or IUI, and about any donor egg and the donor's age.
Does it ask about genetic testing?
It records history only. The Valley Health System form asks which tests for chromosomal or genetic conditions were done this pregnancy, such as cell-free DNA or amniocentesis.
Is there a template for this form?
The sample questions on this page show a typical set.
What happens after the high risk pregnancy intake form is completed?
The maternal-fetal medicine team reviews the answers before the visit. AI Doctor collects history only and does not assess the pregnancy or any symptoms.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
