Little Stars Prenatal Check In Assessment

If you are a Blue Cross and Blue Shield of Kansas City member and have been asked to complete this assessment, please fill out and submit your responses below. This assessment allows our Little Stars® prenatal nurses to make sure your pregnancy stays on track and can help you with questions you might have.

Member Information

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* Required Field

Enter Member Information

  • Member First Name: *
  • Member Middle Initial:
  • Member Last Name: *
  • Member Date of Birth: *
  • Member Group ID: *
  • Member Due Date: *
  • Date of 1st Prenatal Visit:
  • Member Email Address:
  • Member Primary Phone Number: *
  • Enter a 10 digit phone number.
  • Member Alternate Phone Number:
  • Multiple Gestations
  • No Twins Triplets More

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
  • 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

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:

  • 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:

Current Pregnancy Information

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

If yes, please list:

  • 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 your 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
  • 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:

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
  • Has your healthcare provider told you that you have pre-eclampsia (sometimes called gestational high blood pressure) during this pregnancy?
  • Yes
  • No
  • Has your healthcare provider told you that you have an incompetent cervix?
  • 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
  • Is your blood type Rh Negative?
  • Yes
  • No
  • Have you experienced any recent vaginal bleeding?
  • Yes
  • No
  • Have you experienced pre-term labor with this pregnancy?
  • Yes
  • No
  • Have you had placental abruption or placenta previa with this pregnancy?
  • Yes
  • No
  • Are you having pregnancy related pain?
  • Yes
  • No
  • Are you experiencing other pain that was present before this pregnancy?
  • Yes
  • No

Has your healthcare provider recommended restricted activity?

  • Yes, decreased activity
  • Yes, bed rest
  • No restricted activity instructions
  • Have you had an abnormal blood sugar level 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

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 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

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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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.

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