Tell Us About Your Symptoms

Our high risk pregnancy quiz is designed to help you better understand potential complications by answering essential high risk pregnancy questions. This high-risk pregnancy assessment provides insight into factors that may impact your health and your baby’s development. While this tool is informative, it is not a diagnosis—professional evaluation is essential. Explore more options through our other self-assessment forms or learn about comprehensive care on our reproductive health services page for personalized support. These are just some of the reasons why a pregnancy would be considered high-risk, but there are many others as well. As a board-certified Obstetrician, Dr Jones has the training and experience to provide you and your unborn baby with the absolute best and most up-to-date care possible.

Have you had a previous Cesarean delivery or other surgery on the uterus (except for a D&C)?*

Yes
No

Do you have hypertension (high blood pressure) when you are not pregnant or did you develop hypertension during any prior pregnancy (sometimes called pre-eclampsia)?*

Yes
No

Do you have diabetes when not pregnant or did you develop diabetes during any prior pregnancy?*

Yes
No

Do you have Systemic Lupus Erythematosus (lupus or SLE), Sjogren’s syndrome, or another rheumatologic disease?*

Yes
No

Do you have hyperthyroidism or poorly-controlled hypothyroidism?*

Yes
No

Do you have epilepsy or a seizure disorder?*

Yes
No

Are you taking medication for depression, anxiety, ADHD, or other types of psychiatric disorders?*

Yes
No

Have you ever been treated for an ectopic (or tubal) pregnancy?*

Yes
No

Have you ever been told that there is something unusual about the way your uterus or reproductive tract formed or is shaped (such as septate, bicornuate, unicornuate, or didelphic)?*

Yes
No

In any prior pregnancy, did the baby deliver early (prior to 36 completed weeks of pregnancy), either on its own or because it was recommended?*

Yes
No

Have you ever experienced a stillbirth?*

Yes
No

Have you ever lost a pregnancy after the 16th week?*

Yes
No

Have you ever had a baby deliver in the 4th, 5th or 6th month where there was virtually no pain and the baby just seemed to “fall out” or have you ever been told that your cervix is too weak to hold pregnancies in (cervical incompetence)?*

Yes
No

Do you have a history of heart disease or a heart problem that required surgical correction?*

Yes
No

Are you carrying twins or higher order multiples (meaning triplets or higher)?*

Yes
No

Do you currently have or have you ever been treated for fibroid tumors?*

Yes
No

Have you ever delivered a baby that was unusually small (< 5 lb) or excessively large (>9 ½ lb)?*

Yes
No

Do you have a blood disorder that either makes it hard for you to stop bleeding (like von Willebrand’s disease) or prone to make blood clots too easily (like factor V Leiden or anti-phospholipid antibody syndrome)?*

Yes
No

Have you ever been treated for a blood clot in the legs (DVT) or lungs (PE)?*

Yes
No

Have you ever been told your blood contains something that would cause it to attack an unborn baby’s blood and harm the baby (like Rh isoimmunization disease)?*

Yes
No

Have you ever had a pregnancy where the baby had serious birth defects?*

Yes
No

Have you been told you carry something in your genes or DNA that could be passed to your children and cause them to be born with a serious disease (Cystic Fibrosis and Muscular Dystrophy would be examples)?*

Yes
No

Have you experienced excessive blood loss with a prior delivery or needed a blood transfusion because you lost too much blood?*

Yes
No

Name*

First Last

Phone Number*

Email*

I would like to recieve a call to schedule a consultation with Dr. Jones*

Yes
No

Self-Assessment: High Risk Pregnancy

Tell Us About Your Symptoms

Is it urgent? Contact our office to schedule an appointment!