Well and High-Risk Prenatal Check In 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

Personal Information

• Are you still currently employed?
• Yes
• No

• Do you still 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

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

• Do 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

• 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:

• Are you taking your prenatal vitamins?
• Yes
• No

Current Pregnancy Information

• Has your healthcare changed since your first assessment?
• Yes
• No

If yes, please list below:

• Has your birth plan changed since your first assessment?
• Yes
• No

If yes, please select the following options below to the current birth plan:

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

• Have you kept all of your prenatal appointments?
• Yes
• No

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

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

• How much weight have you gained in your pregnancy?
• lbs.

• 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 below:

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

• Have you had Rh antibody screen drawn in this pregnancy yet?
• Yes
• No

• 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

If yes, can you provide the date:

• Has your healthcare provider told you that you have pre-eclampsia (sometimes called gestational high blood pressure) during this pregnancy?
• Yes
• No

• Are you currently on any medication for gestational diabetes?
• Yes
• No

If yes, please list the medication below:

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

• Has your healthcare provider started you on any type of low dose aspirin for pre-eclampsia diagnosis for this pregnancy?
• 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

• Does your healthcare provider check your urine at every appointment?
• Yes
• No

• Has your healthcare provider ever discussed any findings of protein in your urine at check-ups?
• Yes
• No

• Are you experiencing bowel function problems?
• Yes
• No

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

If yes, please list below:

Have you experienced any recent abdominal tightening or cramping?

• 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 ever had Braxton-Hicks contractions?
• Yes
• No

• Has your provider educated you about Braxton-Hicks vs. real contractions?
• Yes
• 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

• Have you felt increasing amounts and freqency of fetal movement?
• Yes
• No

• Has your healthcare provider advised 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

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.

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