HG Initial Visit Baseline Form — English - RSA INSTITUTE - International Patent Miscarriage Specialist

To be completed by the patient

1. General Information

Patient ID

Date completed

Age

Occupation

Height (cm)

Pre-pregnancy weight (kg)

Current weight (kg)

Current gestational age (weeks)

Date of last menstrual period

2. Pregnancy and HG History

Total number of pregnancies

Number of deliveries

Number of miscarriages

Number of induced pregnancy terminations

Number of pregnancy terminations due to HG

Number of previous pregnancies with HG

Describe each previous pregnancy with HG: gestational week at onset, IV fluids or hospitalization, whether the pregnancy was terminated, and the main treatments and their effectiveness.

3. Onset and Severity of Four Core Symptoms in the Current Pregnancy

Symptom	Date / gestational week at onset	Current severity (0–4)	Brief notes
Severe vomiting
Insomnia
Excessive salivation (ptyalism)
Low mood / negative thoughts

Safety note:If there is a current specific plan for self-harm or suicide, preparatory behavior, or a recent attempt, initiate the hospital’s safety assessment process immediately.

4. Symptoms and Neurobehavioral Characteristics Before Pregnancy

Symptom / behavior	None	Mild	Moderate	Severe	Earliest age / date of onset
Low mood or crying easily
Reduced interest / reduced enjoyment
Insomnia or other sleep disturbances
Difficulty concentrating / easily distracted
Forgetfulness / procrastination / difficulty finishing tasks
Repeated cleaning / worries about contamination / repeated checking
Behaviors such as impulsive spending, risk-taking, or taking items you do not need
Markedly low or high sexual desire

Academic Performance and Attention

Academic performance in primary school

Academic performance in middle school

Academic performance in high school / secondary vocational school

Academic performance in college / vocational training

Previous relevant medications or treatments, doses, dates or duration, and effectiveness

5. Behavioral and Developmental History: Infancy, Childhood, and Adolescence

This section records longstanding behavioral and developmental characteristics present before pregnancy. For each item, record whether it occurred, its severity, the age at first onset, and any effects on school, family life, or social interactions.

A. Infancy (ages 0–2)

Symptom / behavior	None	Mild	Moderate	Severe	Age at onset / duration
Frequent crying at night that was difficult to soothe
Difficulty falling asleep or markedly irregular sleep
Especially difficult to soothe / easily irritated
Especially sensitive to sounds, light, or changes in surroundings

B. Childhood (ages 3–12): Activity Level, Attention, and Executive Function

Symptom / behavior	Never	Occasionally	Frequently	Severe / impairs functioning	Age at first onset
Difficulty sitting still / noticeably more active than children of the same age
Frequently running or climbing / difficulty engaging in quiet activities
Difficulty sustaining attention in class, while reading, or while doing homework
Easily distracted by sounds, people, or other things nearby
Frequently forgetting homework, losing things, or being forgetful
Often leaving tasks unfinished / difficulty completing tasks in sequence
Frequently interjecting, blurting out answers, or interrupting others
Difficulty waiting / tendency to make impulsive decisions
Talking noticeably more than children of the same age
Academic performance substantially below ability or highly variable over time

C. Adolescence (ages 13–18): Recurrent Thoughts and Repetitive Behaviors

Symptom / behavior	None	Mild	Moderate	Severe	Age at first onset
Strong fear of dirt, contamination, or infection
Repeated handwashing, bathing, laundry, cleaning, or disinfecting
Repeated checking of door locks, appliances, belongings, or other items
Needing to do certain things in a fixed order, a set number of times, or according to a ritual

D. Adolescence and Young Adulthood: Impulsivity, Concealment, and Rule-Related Behaviors

These behaviors can have many causes and cannot, on their own, establish a diagnosis. Record only the specific behavior, frequency, age at onset, and consequences.

Symptom / behavior	Never	Occasionally	Repeatedly	Significant consequences	Age at first onset
Repeatedly concealing facts or providing information clearly inconsistent with the facts
Repeatedly taking items that belong to others
Impulsive spending, risk-taking, or behavior showing little consideration of consequences

At what age did any of the above symptoms or behaviors first appear?

Were any of the above symptoms or behaviors present before your first pregnancy?

Additional notes: duration, observations from family or school, and any previous assessment or treatment

6. Sensitive History (Optional)

Age at first consensual sexual intercourse

Was your first sexual experience consensual?

Have you ever experienced sexual contact or intercourse without your consent, when you were unable to consent, or under threats or coercion?

Have you ever experienced physical, verbal, financial, or sexual control or abuse by a partner?

Additional information, if you wish to share

HG Initial Visit Baseline Form — English

Hyperemesis Gravidarum (HG) Mechanisms Study | Initial Visit Baseline Form