Free ForwardHealth PreNatal Care Coordination Program Pregnancy Questionnaire (Hmong), F-1105H - Wisconsin

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

STATE OF WISCONSIN

FORWARDHEALTH

KEV PAB CUAM THAUM CEV XEEB TUB COV LUS NUG TXOG CEV TSIS TAB SEEB
PRENATAL CARE COORDINATION PROGRAM PREGNANCY QUESTIONNAIRE
Cov Lus Qhia: Muab ntaus los sis sau kom pom tseeb. Ua ntej pib ua daim ntawv no, yuav tau twm cov lus qhia nyob hauv daim Prenatal Care Coordination Program Pregnancy Questionnaire Completion Instructions, HCF 1105A. NTU I -- QHIA ME NTSIS TXOG TUS TSWV CUAB 1. Npe -- Tus Tswv Cuab (Member) (Lub Xeem, Npe, Npe Nrab)
To be completed by Health Professional Lim Eng A- <20 A- >39 E- H R- AI,A, B,HPI,O

2. Hnub Yug -- Tus Tswv Cuab

3. Hnub Nyoog -- Tus Tswv Cuab

American Indian Black Asian White Hawaiian / Pacific Islander Lwm Cov 7. Muaj Txij Nkawm Los Tsis Tau 6. Kev Kawm Ntawv (Qhia qib siab tshaj plaws uas kawm tiav.) 4. Hom Neeg Hispanic Non-Hispanic 5. Haiv Neeg Qib Qis / Nrab (1-12) _____ Qib Siab (1-4 los yog 5+) _____ 8. Chaw Nyob -- Tus Tswv Cuab (Txoj Kev, Lub Zos, Xeev, Zip Code) Tsis Tau Muaj Muaj 9. Lub Nroog (County)

Edu<12 MS- S

10. Xov Tooj -- Tus Tswv Cuab

11. Lwm Tus Xov Tooj -- Tus Tswv Cuab

12. Peb yuav cuag tau koj li cas? Lub sij hawm twg thiaj li zoo tshaj rau peb hu koj? 14. Npe-- Chaw Kho Mob los yog Tsev Kho Mob (Kws Kho Mob, Tus Tu Neeg Mob, Tus Pab Thaum Tau Me Nyuam)

13. Npe thiab Xov Tooj -- Tus Uas Hu Tau Rau Nws Thaum Muaj Xwm Ceev 15. Tus Tswv Cuab Tus Zauv ID

Kuv tsis muaj ib tus kws los sis qhov chaw kho mob. 16. Ob lub xyoos dhau los no, koj mus cuag kws kho hniav los sis qhov chaw kho hniav tsawg zaus?

NTU II -- CEV XEEB TUB ZAUM NO 1. Thaum twg mam li tau koj tus me nyuam?

2. Hnub koj lub cev ntas zaum tas los no yog hnub twg?

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

3.

Yog tias koj hloov tau qhov xeeb muaj tus me nyuam zaum no, koj xav kom muaj rau thaum twg? Ntxov Zog Tsis Hloov Lig Zog Tsis Hloov Li

5. Koj Hnyav Li Cas Ua Ntej Koj Lub Cev Xeeb Tub:________ Tam Sim No Koj Hnyav Li Cas:_______________________ Koj Siab Li Cas:___________________________________

4. Thawj zaug koj mus tshuaj cev xeeb tub yog thaum twg? __________________ (hlis / xyoos) Kuv tsis tau mus ntsib ib tus twg li Kuv twb teem tau caij yuav mus rau _________________________________. Hlis/Hnub/Xyoos (MM/DD/YY) 6. Puas yog koj xeeb muaj me nyuam ntau tshaj ib tus me nyuam (Ntxaib, Peb Tug)? Yog Tsis Yog

BMI- <19.8 BMI- >26.1

WIC- Y

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

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7. Koj puas xav tias yuav pub niam mis rau me nyuam?

8. Koj puas tau mus tshuaj tus kab mob Human Immunodeficiency Virus (HIV) ib zaug li thaum koj Xav Tsis Xav Tsis Tau Txiav Txim Siab cev xeeb tub zaum no? Tau Tsis Tau 9. Koj puas tau tsob ntshav los sis mob plab ntaum cev ntas ib 10. Koj puas tau txais kev pab cuam txog kev noj kev zaug li? haus los ntawm Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)? Tau Tsis Tau Tau Tsis Tau NTU III -- KEEB KWM CEV XEEB TUB (Yog tias zaum no yog xeeb tub thawj zaug, hla mus rau Ntu IV.) 1. Koj xeeb tub pes tsawg zaus lawm ua 2. Cov Me Nyuam Uas Nyob Puv Caij 3. Cov Me Nyuam Uas Yug Ntxov ntej zaum no? Mam Li Tau Muaj Tsawg Leej Dua 3 Lis Piam Ua Ntej Caij So Muaj Tsawg Leej

PreT Loss 20+ LBW Int<12m

4. Cov Me Nyuam Nchuav los sis Poob Thaum Twb Muaj 20 Lub Lis Piam Rov Saud Lawm Muaj Tsawg Leej

5. Cov Me Nyuam Nchuav los sis Poob Ua Ntej Lawv Muaj 20 Lub Lis Piam Muaj Tsawg Leej

6. Cov Me Nyuam Uas Tseem Muaj Txoj Sia Nyob Muaj Tsawg Leej

7. Cov Me Nyuam Uas Hnyav Tsis Txog 5½ Pounds Thaum Yug Kiag Tau Muaj Tsawg Leej

8. Cov Me Nyuam Uas Hnyav Tshaj 9 Pounds Thaum Yug Kiag Tau Muaj Tsawg Leej

9. Hnub Uas Koj Xeeb Tub Tas Zaum Kawg Yog Hnub Twg

10. Kev Xeeb Tub Zaum Tas Los No Mus Zoo Li Cas Yug Tau Los Ciaj Sia Nchuav Los Sis Poob Lawm NTU IV -- COV KEV TXHAWJ XEEB 1. Koj puas muaj, los sis muaj dua, cov kev mob nram qab no li? Muaj Tsis Muaj Kos Rau Txhua Yam Koj Muaj. Mob Hawb Pob (Asthma). Ntshav Siab (High blood pressure). Mob Kas Cees (Chlamydia, gonorrhea, syphilis, Qaug Dab Peg (Seizures / epilepsy). Mob Txeeb Zis (Urinary tract infection). or genital herpes). Ntshav Qab Zib (Diabetes). Lwm yam mob uas yuav tau mus ntsib kws kho mob. 2. 3. Koj puas mob hniav los sis pos hniav los ntshav thaum koj noj khoom los yog txhuam hniav? Ua ntej xeeb tub, koj puas haus luam yeeb? Yog HAUS, qhia seb ib hnub koj haus khwv yees tsawg tus. Pib txij thaum koj cev xeeb tub los, koj puas haus luam yeeb? Yog HAUS, qhia seb ib hnub koj haus khwv yees tsawg tus. Puas muaj neeg haus luam yeeb hauv koj tsev neeg? Peb lub hlis ua ntej koj cev xeeb tub zaum no, koj puas haus cawv? Yog HAUS, qhia seb ib lis piam koj haus khwv yees tsawg khob. Txij thaum koj xeeb tub los, koj puas haus cawv? Yog HAUS, qhia seb ib lis piam koj haus khwv yees tsawg khob. Xyoos dhau los no, koj puas siv yeeb tshuaj? Mob Haus Tsis Mob Tsis Haus

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

4.

Haus

Tsis Haus

5. 6.

Muaj Haus

Tsis Muaj Tsis Haus

7.

Haus

Tsis Haus

8. 9.

Siv

Tsis Siv Tsis Tau Tsis Muaj

Koj puas tau raug koj tus khub los sis ib tus txheeb ze muab koj ntaus, quab yuam, rhuav, los sis Tau cem? 10. Koj puas ntshai tsis tau luag tsam muaj neeg ua phem ntawm thaj tsam koj nyob? Muaj 11. Lub hlis dhau los no, koj puas tau yoo mov, tsis tau noj thaum koj tshaib plab, los sis tau mus siv cov chaw pab zaub mov vim tu ncua zaub mov los sis tsis muaj nyiaj Tau yuav zaub mov? 12. Peb lub hlis dhau los no, koj puas muaj teeb meem txog vaj tsev nyob? 13. Koj puas muaj teeb meem txog kev thauj mus los, zov me nyuam, los sis lwm yam uas ua rau koj mus kho mob tsis tau los yog mus thov kev pab tsis tau li tau teem tseg lawm? 14. Koj puas muaj teeb meem txog kev nyuaj siab los sis tau txais kev pab tawm tswv yim los sis tshuaj noj pab kev mob puas siab puas ntsws? Muaj Muaj Muaj

Tsis Tau Tsis Muaj Tsis Muaj Tsis Muaj

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

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15. Lub hlis dhau los no, puas muaj qhov ua rau koj tsis xav ua dab tsi li, los sis meem txom koj ua rau koj qaug zog, nyuaj siab, los sis tas kev cia siab? 16. Yog muab luj no koj kev nyuaj siab nyob rau theem twg? Siab

Yog

Tsis Yog Qi

Nruab Nrab

17. Muaj pes tsawg tus neeg koj xam tau tias yuav pab tau koj thaum koj thov lawv pab? 0 1-2 3+ 18. Cov nram qab no, yam twg ua rau koj txhawj tshaj? Kos rau txhua qhov uas koj txhawj txog. Teeb meem nyiaj txiag. Kuv kev sib raug zoo nrog kuv tus khub. Kuv txoj hauj lwm. Kuv tus khub tsis xav yuav tus me nyuam no. Kuv tus khub txoj hauj lwm los sis poob hauj lwm. Kev mob plab yug me nyuam. Kuv tus khub kev haus cawv siv yeeb tshuaj. Kev tu tus me nyuam no. Kuv kev haus cawv siv yeeb tshuaj. Kev tu cov me nyuam kuv muaj lawm. Kuv tus khub raug kaw lawm. Lwm Yam __________________________________________.

19. Dab tsi ua rau koj txhawj tshaj plaws?

20. Koj yuav daws koj tej teeb meem li cas?

21. Leej twg uas koj xam tau tias yuav pab tau koj tej dej num uas koj ua txhua hnub, xws lis zov me nyuam, npaj zaub mov noj, ntxhua khaub ncaws, los sis pab thauj mus los?

22. Yam dab tsi uas koj xav kawm ntxiv? Kos rau txhua yam ua koj xav kawm. Me nyuam kev loj hlob. Kev tau me nyuam. Kev pub niam mis. Tswj kev xeeb txob tsis tau zoo nyob thaum xeeb tub. Kev tu tus me nyuav mos liab. Kev noj haus thaum xeeb tub. Kev caiv tsis pub muaj me nyuam. Tswj kev nyuaj siab ntxhov plawv. Nrhiav kev noj qab haus huv rau koj thiab Lwm Yam _____________________________________________. koj tus me nyuam. Yuav txwv luam yeeb li cas. Dej cawv tej teeb meem tsis zoo rau tus niam thiab tus me nyuam. 23. Lwm yam xav muab qhia ntxiv

NTU V -- HAUV QAB NO CIA RAU COV NEEG KHIAV HAUJ LWM MAM TEEV RAU Is the recipient eligible for Prenatal Care Coordination (PNCC) services? Yes, based on a number of factors _________ or age ________. No. SIGNATURE -- Staff Completing Assessment Date Signed

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

Date Signed