Well and High-Risk Prenatal Welcome Assessment

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: