Recurrent Miscarriage Intake Form
What a recurrent miscarriage intake form asks, with sample questions on past pregnancies, losses, testing, and family history.
A recurrent miscarriage intake form records each past pregnancy and loss, earlier testing, medical and family history, and lifestyle before a visit about repeated pregnancy loss. The questions on this page are built from BC Women's Hospital's recurrent pregnancy loss referral form in Canada and the ASRM Infertility History Form.
Recurrent miscarriage intake form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a recurrent miscarriage 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 recurrent miscarriage intake form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- How many pregnancies have you had in total?Pregnancy history
- How many pregnancies ended in a live birth?Pregnancy history
- How many weeks along was each loss?Pregnancy losses
- How was each loss managed?Pregnancy losses
- Was chromosome testing done on any loss?Earlier testing
- Have you had an HSG or hysteroscopy?Earlier testing
- Have you ever had a blood clot?Medical history
- Do you have thyroid gland problems?Medical history
- Has anyone in your family had blood clots?Family history
- Does your family have chromosome or birth defects?Family history
- Do you smoke cigarettes, and how many?Social history
- Do you use marijuana or other drugs?Social history
These are examples to read, not a form to fill in.
Recurrent miscarriage intake form: FAQ
What does a recurrent miscarriage intake form ask?
The sample questions on this page are based on BC Women's Hospital's recurrent pregnancy loss referral form (Canada) and the ASRM Infertility History Form. This page groups them into six areas: pregnancy history, pregnancy losses, earlier testing, medical history, family history, and social history.
Who fills in a recurrent miscarriage intake form, and when?
At BC Women's Hospital in Canada, the patient fills in an intake questionnaire and returns it within three weeks. A nurse then calls to review the history.
Does it ask about each loss separately?
Yes. The BC Women's referral form lists each pregnancy with the gestational age, the outcome, how it was managed, and whether chromosome testing was done.
Does a recurrent miscarriage intake form ask about earlier tests?
It can. The BC Women's referral form asks for records such as ultrasounds, pathology, chromosome results, and an HSG or hysteroscopy.
Does it ask about family history?
Yes. The ASRM form asks whether relatives have had blood clots, birth defects, chromosome defects, and other conditions, and how each person is related.
What happens after the form is completed?
The practice's team reviews the answers. At BC Women's Hospital, a doctor reviews the history at the first visit and outlines a care plan.
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.
