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Your JavaScript is not enabled!

To ensure the proper functionality of electronic forms you must have JavaScript enabled and be using a current version of your browser.

Note that not filling in required fields (Marked with an *) will cause your submission to be rejected.

Select your browser type and follow these instructions to activate and enable JavaScript or contact your administrator if you continue to experience issues.

Internet Explorer

Follow these instructions to activate and enable JavaScript in Internet Explorer.

PC

Click the gear icon/Tools menu to the right of the Internet Explorer address bar.
Select Internet Options from the drop-down menu.
Next, select the Security tab at the top of the dialog box.
Then, select the earth (Internet) icon.
Then select the Custom Level button under the Security level for this zone section.
Locate the Scripting section within the list.
Under Active Scripting, select Enable, then hit OK.
Answer yes to the following conformation box.
Hit OK to close the Internet Options window.
Finally, refresh your browser.

Firefox

Follow these instructions to activate and enable JavaScript in Firefox.

PC & MAC

Open a new Firefox browser window or tab.
Copy the following then paste it into the Firefox address bar:about:config
Hit the Enter key.
On the following page, click the button: "I'll be careful, I promise!"
Find the javascript.enabled row under the Preference Name heading.
Double-click anywhere within the javascript.enabmed row to toggle the value from "False" to "True".
Finally, refresh your browser.

Safari

Follow these instructions to activate and enable JavaScript in Safari.

PC

In the Edit drop-down menu at the top of the window, select Preferences...
Select the Security icon/tab at the top on the window.
Then, click the Enable JavaScript checkbox.
Close the dialog box to save your changes.
Finally, refresh your browser.

MAC

Select Safari from the Apple/System bar at the top of the screen.
From the drop-down menu, select Preferences.
Select the Security icon/tabg at the top of the window.
Check the Enable JavaScript checkbox under the Web content category.
Close the dialog box to save your changes.
Finally, refresh your browser.

Opera

Follow these instructions to activate and enable JavaScript in Opera.

PC

In the Tools drop-down menu at the top of the window, select Preferences...
Select the Advanced tab at the top on the Preferences window.
Find the Content item in the list on the left-side of the window and select it.
Then, click the Enable JavaScript checkbox.
Click Ok to save your changes and close the Preferences window.
Finally, refresh your browser.

MAC

Select Opera from the Apple/System bar at the top of the screen.
From the drop-down menu, select Preferences.
Select the Security icon/tabg at the top of the window.
Check the Enable JavaScript checkbox under the Web content category.
Close the dialog box to save your changes.
Finally, refresh your browser.

Chrome

Follow these instructions to activate and enable JavaScript in Chrome.

PC

To the right of the address bar, click the icon with 3 stacked horizontal lines.
From the drop-down menu, select Settings
At the bottom of the page, click the Show advanced settings... link.
Under the Privacy section, click the Content settings... button.
Under the JavaScript heading, select the Allow all sites to run JavaScript radio button.
Finally, refresh your browser.

MAC

Select Chrome from the Apple/System bar at the top of the screen.
Select Preferences... from the drop-down menu.
In the left-hand column, select Settings from the list.
At the bottom of the page, click the Show advanced settings... link.
Under the Privacy section, click the Show advanced settings... button.
Under the JavaScript heading, select Allow all sites to run JavaScript radio button.
Finally, refresh your browser.

iOS

Follow these instructions to activate and enable JavaScript in iOS on the iPhone and iPad.

Select the Settings application/icon on the iPhone home screen.
Select Safari on the following screen.
Select Advanced, located near the bottom of the following screen.
Move the JavaScript toggle to the right so that it highlights green.

Andriod

Follow these instructions to activate and enable JavaScript on your Android.

Select Browser or Internet to open the web browser.
Select Menu
Select More then Settings.
Finally select Enable JavaScript

Please use a desktop or laptop computer to submit this form. We are unable to process submissions from smartphones and tablets at this time.

Prenatal Health Assessment Form

Complete the questions below and a member of our Care Team will contact you with next steps.

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Member Information

Blue KC Member ID

Preferred Email Address

Primary Phone Number:

Enter a 10 digit phone number.

Pregnancy Information

First day of your last menstrual period (LMP)?

Estimated Delivery date:

Have you had a positive pregnancy test?
Yes
No

Is this your first pregnancy?
Yes
No

If no, number of pregnancies?

Any past pregnancy complications?
Yes
No

If yes, please explain:

Do you currently have an OB Provider?
Yes
No

If yes, please provide their name and your next appointment date:

Medical History

Check all that apply:

Anxiety or depression
Asthma or lung disease
Diabetes (Type 1, Type 2, or Gestational)
Heart Condition
High Blood Pressure
Seizure disorder
Thyroid disease
Other Medical Conditions

Have you had any surgeries??
Yes
No

If yes, please list the procedures:

Medications & Allergies

Current medications or supplements, including vitamins:

Do you take a prenatal vitamin?
Yes
No

Do you have any medication or food allergies?
Yes
No

If yes, please list them:

Lifestyle & Safety

Do you currently use:

Tobacco or vaping products?
Yes
No

Alcohol?
Yes
No

Recreational drugs?
Yes
No

Do you feel safe at home and in your relationships?
Yes
No

Do you have enough food, housing, and transportation for medical visits?
Yes
No

Current Symptoms

Check all that apply:

Abdominal pain or cramping
Burning or pain with urination
Concerns about baby's movement (if applicable)
Nausea or vomiting
Severe headaches or vision changes
Swelling of the face, hands, or feet
Vaginal bleeding or spotting
My symptoms are not listed

Education & Support Preferences

Are you interested in breastfeeding education?
Yes
No

Are you in need of mental health resources?
Yes
No

Do you have questions about:

Childbirth or parenting classes
Exercise during pregnancy
Nutrition or weight gain
Vaccines (Tdap / flu)

Please list any additional questions or concerns you would like to discuss with your care team:

By checking this box and submitting this assessment, you agree that a Blue KC Care Manager may reach out to you to with a link and access code to download the Blue KC Care Management app. This secure app allows you to conveniently communicate updates with your Blue KC Care Manager. Your information can only be viewed by yourself and the Care Manager, and includes the following activities, resources, and functionality:

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
Note: 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.

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.