Well and High-Risk Prenatal Welcome Assessment

If you are pregnant and are a Blue Cross and Blue Shield of Kansas City (Blue KC) member, please fill out and submit the following assessment to be enrolled in the Well and High-Risk Prenatal Program. This program, along with regular prenatal visits, is another way to spot potential health problems early so your doctor can address them accordingly. As part of this program you will be directed to resources that can help answer pregnancy-related questions. If you are experiencing a more challenging pregnancy, please contact one of our prenatal nurse case managers at 816-395-2060 to help navigate your pregnancy and ensure you are getting all the care and support you need.

Member Information

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Blue KC ID (Not SS#): *
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Member First Name: *
Member Middle Initial:
Member Last Name: *
Member Date of Birth: *
Member Group ID: *
Member Email:
Member Primary Phone Number: *
Enter a 10 digit phone number.
Member Alternate Phone Number:
Enter a 10 digit phone number.

Are you currently pregnant?

No - Please disregard this assessment.

What is the date of your first prenatal visit?

What is your height?

What is your pre-pregnancy weight?

What is your current weight?

Due date:

Pregnancy History

Is this your first pregnancy?
Yes
No

Including this pregnancy, how many pregnancies have your had?

How many resulted in live births?

How many resulted in a miscarriage or abortion?

Have you ever experienced a stillbirth or fetal death?
Yes
No

Have you delivered a baby before 37 weeks gestation?
Yes
No

Have you ever delivered a post-term baby (after 42 weeks gestation)?
Yes
No

If yes, was this your last pregnancy?
Yes
No

Have you had a previous c-section delivery?
Yes
No

Have you ever delivered a baby larger than 9 pounds at birth?
Yes
No

Have you ever delivered a baby smaller than 5 1/2 pounds at birth?
Yes
No

Have you given birth in the past 12 months?
Yes
No

Have you ever experienced pre-term labor in a previous pregnancy?
Yes
No

Have you ever experienced placental abruption or placenta previa in a previous pregnancy?
Yes
No

Did you develop gestational diabetes in a past pregnancy?
Yes
No

Do you have a history of frequent urinary tract infections?
Yes
No

Current Pregnancy Information

Which healthcare provider or specialist are you seeing for your pregnancy needs?

Mid-wife-Doula
Mid-wife-nurse certified
OB-GYN specialist

What is your healthcare provider's name and phone number?

At what week did you begin your prenatal care with your healthcare provider?

Where do you plan to deliver your baby

Hospital
Birthing center
Home

If hospital or birthing center, list name below:

Have you discussed a birth plan with your healthcare provider?
Yes
No

If yes, what is your delivery plan?

Vaginal
C-Section
VBAC (vaginal birth after c-section)

Have you kept all of your prenatal appointments?
Yes
No

Are you taking prenatal vitamins?
Yes
No

Do you feel you are eating a healthy, well balanced pregnancy diet?
Yes
No

Are you drinking at least 64 oz. of water daily?
Yes
No

Do you feel you are having an unusual amount of nausea or vomiting this pregnancy?
Yes
No

Are you gaining weight at the rate recommended by your healthcare provider?
Yes
No

Are you seeing a specialist other than your healthcare provider?
Yes
No

If yes, please list:

Do you have a history of high blood pressure, blood pressure controlled with medication, or have newly diagnosed high blood pressure?

Yes, I have a new diagnosis of high blood pressure
Yes, I had high blood pressure prior to this pregnancy
No, I do not have high blood pressure

Are your currently on a diet plan for gestational diabetes?
Yes
No

Have you had a Pap smear in the past for which your healthcare provider advised follow up treatments or exams?
Yes
No

Has your healthcare provider told you that you have an incompetent cervix?
Yes
No

Has your provider discussed any treatment plans for incompetent cervix with you?
Yes
No

Have you had any urinary tract infections this pregnancy?

Yes, I've had a urinary tract infection this pregnancy
Yes, I currently have a urinary tract infection
No urinary tract infections this pregnancy

Are you experiencing bowel function problems?
Yes
No

Has your healthcare provider determined that special testing is necessary for you or your baby?
Yes
No

If yes, can you provide the date?

Is your blood type Rh Negative?
Yes
No

Have you had to receive the Rhogam shot during this pregnancy or in any previous pregnancies.
Yes
No

Have you experienced any vaginal bleeding with this pregnancy?

Yes, before the 12th week
Yes, after the 12th week
Yes, after the 18th week
No vaginal bleeding

Have you experienced pre-term labor in this pregnancy?
Yes
No

Do you currently have diabetes (diabetes prior to becoming pregnant or gestational diabetes)?
Yes
No

Are you being treated for any other medical conditions?
Yes
No

If yes, please list:

Have you experienced any abdominal tightening or cramping after the 12th week of your pregnancy?

Yes, randomly
Yes, 2-3 times per hour, more than 3-4 times per day
Yes, 4 or more times per hour
No

Have you noticed any unusual vaginal discharge or leaking of vaginal fluids?
Yes
No

Do you have swelling in your feet, ankles or legs that does not resolve with rest?
Yes
No

Has your healthcare provider advised you that your pregnancy ultrasound (sonogram) was abnormal?
Yes
No

Have you been seen in the Emergency Room this pregnancy?
Yes
No

Have you been hospitalized for any reason this pregnancy?
Yes
No

Have you discussed receiving a seasonal flu shot or other vaccinations with your healthcare provider?
Yes
No

Do you have any dental concerns at this time?
Yes
No

Personal Information

Are you currently employed?
Yes
No

If yes, what type of work do you do?

Do you have the financial resources for basic needs such as food/shelter/clothing?
Yes
No

Do you have a stable or permanent residence?
Yes
No

Do you have someone you can rely on for emotional and/or social support or assistance?
Yes
No

Is there any violence in your home or do you fear for your safety or the safety of others in your home?
Yes
No

How would you rate your stress level?
Low
Moderate
>High

How would you feel you need help managing your stress?
Yes
No

Are you currently, or have you in the past, been treated for a mental health disorder?
Yes
No

Since learning you are pregnant, which statement best describes your alcohol use?

Less than 1 drink/week
One drink per day
More than one drink per day
I do not drink alcohol

Do you use tobacco products?
Yes
No

Do you use medical marijuana, illegal substances, prescription pain medications, sleeping pills or tranquilizers recreationally?
Yes
No

Are you taking any prescription medications other than your prenatal vitamins?
Yes
No

If yes, please list below:

Other than prenatal vitamins, do you take any over-the-counter medications, herbal or nutritional supplements, or home remedies?
Yes
No

If yes, please list below:

By checking this box and upon completion of this survey, you agree that a Blue KC Prenatal Nurse Case Manager may reach out to you to with a link and access code to download the Blue KC Care Management app powered by Wellframe. This free and secure app can help stay healthy throughout your pregnancy and is a simple and convenient way your Blue KC Prenatal Nurse Case Manager can connect with you. Your information will/can only be viewed by yourself and the nurse case manager, and includes the following:

Small check-in surveys to assess how you are doing and feeling
Weekly gestation updates and weekly comparisons of baby’s size
Track your steps and set daily medication reminders, including your prenatal vitamins
Text directly with your Blue KC Prenatal Nurse throughout your pregnancy and postpartum journeys, should you have any questions or needs

The Blue KC Care Management app is not meant for emergency needs, and the nurse may only respond during Blue KC business hours from the hours of 8 a.m. – 5 p.m. Central Standard Time. Blue KC is closed on weekends and holidays. In the event of an emergency, please call your provider.

Should you wish to not enroll in this portion of the prenatal program, please uncheck the box.

If you experience issues submitting this form, please print and fax it to (816) 926-4215.

If you have questions, contact Blue KC at (816) 395-3964.

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