Free F-1105 Prenatal Care Coordination Pregnancy Questionnaire - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1105 (02/09)

STATE OF WISCONSIN

FORWARDHEALTH

PRENATAL CARE COORDINATION PREGNANCY QUESTIONNAIRE
Instructions: Type or print clearly. Before completing this form, read the Prenatal Care Coordination Program Pregnancy Questionnaire Completion Instructions, F-1105A. SECTION I -- GENERAL INFORMATION 1. Name -- Member (Last, First, Middle Initial) 4. Ethnicity
To Be Completed by Health Professional Lim Eng A- <20 A- >39 E- H R- AI,A, B,HPI,O

2. Date of Birth -- Member

3. Age -- Member

Hispanic Non-Hispanic

5. Race

American Indian Asian

Black White Hawaiian / Pacific Islander Other
7. Marital Status

6. Education (Indicate highest grade completed.)

Primary / Secondary (1-12) _____

College (1-4 or 5+) _____

Single

Married
9. County
Edu<12 MS- S

8. Address -- Member (Street, City, State, ZIP Code)

10. Telephone Number -- Member 12. What is the best way to contact you? When is the best time to contact you? 14. Name -- Medical Provider or Clinic (Doctor, Nurse Practitioner, Midwife)

11. Other Telephone Number -- Member 13. Name and Telephone Number -- Emergency Contact Person 15. Member Identification Number



I do not have a medical provider.

16. How many times have you been to a dentist or dental clinic in the last two years?

SECTION II -- CURRENT PREGNANCY 1. When is your baby due?

2. What was the date of your last menstrual period?

Tim- L,NAA PNC- 2,3,N

3. If you could change the timing of this pregnancy, when would you want it? Earlier No change Later Not at all

5. Your Weight Before Pregnancy Your Current Weight Your Height 7. Are you thinking about breastfeeding your baby? Undecided 9. Have you had any bleeding or cramping?

4. When was your first medical appointment for prenatal care? (month / year) I have not seen anyone yet. I have an appointment set for . (MM/DD/YY) 6. Are you pregnant with more than one baby (Twins, Triplets)?

BMI- <19.8 BMI- >26.1

Yes

No

Yes

No



Yes

No

8. Have you had a Human Immunodeficiency Virus (HIV) test during this pregnancy? Yes No 10. Are you receiving nutrition services from the WIC- Y Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)? Yes No Continued

PRENATAL CARE COORDINATION PROGRAM PREGNANCY QUESTIONNAIRE F-1105 (02/09)

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SECTION III -- PREGNANCY HISTORY (If this is a first pregnancy, skip to Section IV.) 1. How many times have you been pregnant 2. Number of Full-Term Babies 3. Number of Babies Born More before? Than Three Weeks Early

PreT Loss 20+ LBW Int<12m

4. Number of Miscarriages or Other 5. Number of Miscarriages or Other 6. Number of Living Children Pregnancy Losses at 20 or More Weeks Pregnancy Losses Before 20 Weeks

7. Number of Babies Weighing Less Than 5½ Pounds at Birth

8. Number of Babies Weighing More Than Nine Pounds at Birth

9. Date Last Pregnancy Ended

10. Outcome of Last Pregnancy Live Birth Miscarriage / Other Loss SECTION IV -- CONCERNS 1. Do you have, or have you ever had, any of the following conditions? Yes No Check all that apply. Asthma. High blood pressure. Chlamydia, gonorrhea, syphilis, Seizures / epilepsy. or genital herpes. Urinary tract infection. Diabetes. Other illness, infection, or condition requiring medical care. 2. Do you have dental pain or bleeding gums when you eat or brush your teeth? 3. Before pregnancy, did you smoke cigarettes? If Yes, indicate the average number of cigarettes smoked per day. 4. Since you have been pregnant, have you smoked cigarettes? If Yes, indicate the average number of cigarettes smoked per day. 5. Does anyone in your household smoke? 6. In the three months before your current pregnancy, did you use any form of alcohol? If Yes, indicate the average number of drinks consumed per week. 7. Since you have been pregnant, have you used alcohol? If Yes, indicate the average number of drinks consumed per week. 8. In the past year, have you used street drugs? 9. Have you ever been physically, sexually, emotionally, or verbally abused by your partner or someone close to you? 10. Do you feel unsafe where you live? 11. During the past month, did you miss any meals, not eat when you were hungry, or use a food pantry because there was not enough food or money to buy food? 12. Have you had any housing problems in the past three months? 13. Do you have transportation, child care, or other problems that prevent you from keeping your health care or social services appointments? 14. Have you had problems with depression or received counseling or medications for mental health concerns? 15. During the past month, have you had little interest in doing things, or have you been bothered by feeling down, depressed, or hopeless? 16. How do you rate your current stress level? 17. How many people can you count on when you need help?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 1-2

No No No No No No No No No No No No No No 3+ Continued

1 --Y 2 --Y 4--Y 7--Y 8--Y 9 --Y 10 -- Y 11 --- Y 12 -- Y 13 -- Y 14 -- Y 15 -- Y 16 -- H 17 -- 0

High 0

Medium Low

PRENATAL CARE COORDINATION PROGRAM PREGNANCY QUESTIONNAIRE F-1105 (02/09)

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SECTION IV -- CONCERNS (Continued) 18. Which of these things worry you a lot? Check all that apply. Money problems. My relationship with my partner. My job. My partner did not want this pregnancy. My partner's job or unemployment. Labor and delivery. My partner's drinking or drug use. Caring for this baby. My own drinking or drug use. Caring for my other children. My partner is in jail. Other 19. What worries you the most?

.

20. What do you do to deal with your problems?

21. Who can you count on for help with everyday activities, such as child care, meals, laundry, or transportation?

22. What topics would you like to learn more about? Check all that apply. Baby's growth and development. Labor and delivery. Breastfeeding. Managing the discomforts of pregnancy. Caring for your newborn. Nutrition during pregnancy. Family planning / birth control. Managing stress. Getting health care for you and your baby. Other How to stop smoking. Effects of alcohol on mother and baby's health. 23. Additional Information

.

SECTION V -- TO BE COMPLETED BY HEALTH PROFESSIONAL Is the member eligible for Prenatal Care Coordination (PNCC) services?

Yes, based on a number of factors No.
SIGNATURE -- Staff Completing Assessment

or age

. Date Signed

SIGNATURE -- Qualified Health Professional (If Different from Above)

Date Signed

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