"Initial Perinatal Risk Assessment Form - Comprehensive Perinatal Services Program" - California

This fillable "Initial Perinatal Risk Assessment Form - Comprehensive Perinatal Services Program" is a document issued by the San Bernardino County Department of Public Health specifically for California residents.

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COMPREHENSIVE PERINATAL SERVICES PROGRAM
INITIAL PERINATAL RISK ASSESSMENT
DATE _____________ NAME ____________________________ AGE _____ EDC __________
(Note: Medical history and anthropometric information is available on OB-Medical History forms.)
(Note: Complete Diet Recall at this time if not already completed.)
Please answer the following questions by marking a √ in the
or by writing in the blank space
1.
1.
What languages do you speak?
Other __________
L
M
H
English
Spanish
2.
2.
What languages do you read?
Other __________
L
M
H
English
Spanish
3.
3.
How many years of school have you finished? ____________years
L
M
H
4.
Do you have a job?
What kind of work? _________________
4.
Yes
No
L
M
H
5.
Does your partner have a job?
What kind of work? _________________
5.
Yes
No
L
M
H
6.
6.
Are you on a special diet?
If you are on a special diet, what kind?
Yes
No
L
M
H
Weight loss
low fat/low cholesterol
low salt
diabetic
Other _______________________________________________
7.
7.
Are you vegetarian?
L
M
H
Yes
No
If yes, do you use milk products (milk, cheese, yogurt) and / or eggs?
Yes
No
8.
Are you allergic to any foods, or do you try not to eat any foods?
8.
L
M
H
If yes, what _______________________________________________
Yes
No
9.
L
M
H
9.
How many cups, glasses or cans of these do you drink every day?
water __________
milk ____________
juice ____________
diet soda ___________
Punch/kool aid _____
coffee _________
tea ____________
soda _______________
10.
10.
How many times a day do you usually eat (including snacks)? __________________________
L
M
H
11.
Do you have
11.
L
M
H
nausea
How often? ________________________
Yes
No
vomiting
How often? ________________________
Yes
No
poor appetite
How often? ________________________
Yes
No
weight loss
How many pounds? _________________
Yes
No
diarrhea
How often? ________________________
Yes
No
constipation
How often? ________________________
Yes
No
heartburn
How often? ________________________
Yes
No
other _________________________________________
12.
L
M
H
12.
What home remedies, food supplements, or herbs are you taking?
Ginseng
How often? ________________________
Yes
No
Ma Huang (Ephedra)
How often? ________________________
Yes
No
Manzanilla (Chamomile)
How often? ________________________
Yes
No
Hierba buena
How often? ________________________
(Peppermint)
Yes
No
13.
L
M
H
other _________________________________________
13.
During this pregnancy, have you eaten
maicena (cornstarch)
How often? ________________________
Yes
No
laundry starch
How often? ________________________
Yes
No
dirt or clay
How often? ________________________
Yes
No
paste or plaster
How often? ________________________
Yes
No
freezer frost
How often? ________________________
Yes
No
other _________________________________________
14.
L
M
H
14.
During this pregnancy, are you taking
aspirin
How often? ________________________
Yes
No
cold medicine
How often? ________________________
Yes
No
allergy/sinus medicine
How often? ________________________
Yes
No
diet pills
How often? ________________________
Yes
No
prenatal vitamins
How often? ________________________
Yes
No
other vitamins
How often? ________________________
Yes
No
iron pills
How often? ________________________
Yes
No
other __________________________________________
PROVIDER INFORMATION:
Provider Name: __________________________
COMPREHENSIVE PERINATAL SERVICES PROGRAM
INITIAL PERINATAL RISK ASSESSMENT
DATE _____________ NAME ____________________________ AGE _____ EDC __________
(Note: Medical history and anthropometric information is available on OB-Medical History forms.)
(Note: Complete Diet Recall at this time if not already completed.)
Please answer the following questions by marking a √ in the
or by writing in the blank space
1.
1.
What languages do you speak?
Other __________
L
M
H
English
Spanish
2.
2.
What languages do you read?
Other __________
L
M
H
English
Spanish
3.
3.
How many years of school have you finished? ____________years
L
M
H
4.
Do you have a job?
What kind of work? _________________
4.
Yes
No
L
M
H
5.
Does your partner have a job?
What kind of work? _________________
5.
Yes
No
L
M
H
6.
6.
Are you on a special diet?
If you are on a special diet, what kind?
Yes
No
L
M
H
Weight loss
low fat/low cholesterol
low salt
diabetic
Other _______________________________________________
7.
7.
Are you vegetarian?
L
M
H
Yes
No
If yes, do you use milk products (milk, cheese, yogurt) and / or eggs?
Yes
No
8.
Are you allergic to any foods, or do you try not to eat any foods?
8.
L
M
H
If yes, what _______________________________________________
Yes
No
9.
L
M
H
9.
How many cups, glasses or cans of these do you drink every day?
water __________
milk ____________
juice ____________
diet soda ___________
Punch/kool aid _____
coffee _________
tea ____________
soda _______________
10.
10.
How many times a day do you usually eat (including snacks)? __________________________
L
M
H
11.
Do you have
11.
L
M
H
nausea
How often? ________________________
Yes
No
vomiting
How often? ________________________
Yes
No
poor appetite
How often? ________________________
Yes
No
weight loss
How many pounds? _________________
Yes
No
diarrhea
How often? ________________________
Yes
No
constipation
How often? ________________________
Yes
No
heartburn
How often? ________________________
Yes
No
other _________________________________________
12.
L
M
H
12.
What home remedies, food supplements, or herbs are you taking?
Ginseng
How often? ________________________
Yes
No
Ma Huang (Ephedra)
How often? ________________________
Yes
No
Manzanilla (Chamomile)
How often? ________________________
Yes
No
Hierba buena
How often? ________________________
(Peppermint)
Yes
No
13.
L
M
H
other _________________________________________
13.
During this pregnancy, have you eaten
maicena (cornstarch)
How often? ________________________
Yes
No
laundry starch
How often? ________________________
Yes
No
dirt or clay
How often? ________________________
Yes
No
paste or plaster
How often? ________________________
Yes
No
freezer frost
How often? ________________________
Yes
No
other _________________________________________
14.
L
M
H
14.
During this pregnancy, are you taking
aspirin
How often? ________________________
Yes
No
cold medicine
How often? ________________________
Yes
No
allergy/sinus medicine
How often? ________________________
Yes
No
diet pills
How often? ________________________
Yes
No
prenatal vitamins
How often? ________________________
Yes
No
other vitamins
How often? ________________________
Yes
No
iron pills
How often? ________________________
Yes
No
other __________________________________________
PROVIDER INFORMATION:
Provider Name: __________________________
COMPREHENSIVE PERINATAL SERVICES PROGRAM
INITIAL RISK ASSESSMENT
15.
How do you plan to feed your baby?
15.
Breast
Bottle
Both
not sure
L
M
H
16.
Have you breastfed a baby before?
16.
Yes
No
L
M
H
17.
a. Where are you living right now?
17.
House
Apartment
Motel
L
M
H
in a friend’s house or apartment
Car
Street
other _______________
b. How long have you lived there?
_________________________________
18.
How many people live with you?
18.
L
M
H
no one
1-3 others
4-6 others
7 or more others
Who lives with you?
live alone
husband/partner
parents
in-laws
your children
other’s children
friends
other family
How many children are in your household? __________________________________________________
19.
L
M
H
19.
If you are worried about something, who do you talk to? _______________________________________
husband/partner
parents
grandparents
other relatives
friend
other person ______________________________________________
20.
L
M
H
20.
Do you have (√
if yes)
electricity
hot water
refrigerator
stove or oven
transportation
a telephone
heating
21.
L
M
H
21.
Are you usually able to (√
if yes)
buy enough food
pay rent
pay other bills
22.
Have you ever had trouble finding a doctor,
22.
L
M
H
or getting medical help for yourself or family?
Yes
No
If yes, explain ________________________________________________________________________
23.
Are you on WIC (Women, Infants & Children) Program?
Yes
No
23.
L
M
H
24.
Do you have an infant car seat?
Yes
No
24.
L
M
H
25.
Do you use your car seat belt?
Yes
No
25.
L
M
H
26.
Was your pregnancy planned?
Yes
No
26.
L
M
H
27.
How does the baby’s father feel about this pregnancy?
27.
L
M
H
doesn’t care
doesn’t know
angry
happy
sad
other ________
28.
How do you feel about this pregnancy?
28.
L
M
H
don’t care
angry
happy
sad
other _______
29.
Have you ever had any of the following?
29.
L
M
H
miscarriage
abortion
stillbirth
fetal demise
neonatal death
premature birth
none
When did it happen? _____________________________________________________________________
What/who helped you get through this? ______________________________________________________
30.
Do you have any traditional, cultural, or religious customs about pregnancy or childbirth
30.
L
M
H
you would like supported?
Yes
No
If yes, please explain ____________________________________________________________________
31.
Since becoming pregnant, which of the following have you had? (√
if yes)
31.
L
M
H
problem sleeping
excessive worrying
crying
depression
sadness
none
other ___________________________________
32.
Are you taking medicine for your nerves?
32.
L
M
H
Name of Medicine ________________________________
Yes
No
33.
What two problems in your life cause you the most trouble?
33.
L
M
H
1. _____________________________________
2. ______________________________________
34.
Have you ever thought about, planned, or tried to hurt yourself?
Yes
No
34.
L
M
H
35.
Have you ever thought about, planned, or tried to hurt someone else?
Yes
No
35.
L
M
H
36.
In the past year, have you been slapped, hit, kicked, or otherwise physically hurt by
36.
L
M
H
someone?
Yes
No
By whom? (check all that apply)
partner/husband
ex-husband
parent
step-parent
stranger
brother/sister
# times hurt ____________
other _____________________
COMPREHENSIVE PERINATAL SERVICES PROGRAM
INITIAL PERINATAL RISK ASSESSMENT
STATUS
37.
On this picture
mark the area of the body
37.
L
M
H
where you have been hurt.
38.
For how many months or years have you been hurt by this person? ______________________________
38.
L
M
H
Not applicable
39.
How many cigarettes do you smoke each day?
39.
L
M
H
don’t smoke
less than ½ pack
½ pack
½ to 1 pack
1-2 packs
2-3 packs
More than 3 packs
40.
Do you live with anyone who smokes?
Yes
No
40.
L
M
H
41.
Check all that apply:
41.
L
M
H
a. Does the father of your baby use drugs or drink alcohol?
Yes
No
Do/did your parents use drugs or drink alcohol?
Yes
No
Do/did you have friends who use drugs or drink alcohol?
Yes
No
b. What drugs did you use before this pregnancy?
cocaine
marijuana
speed, methamphetamines
PCP
heroin
none
other _______________________________________
c. How often do you drink beer, wine, or liquor?
daily
weekends
1-2 times a month
rarely or never
Have your alcohol habits changed since you became pregnant?
Yes
No
if yes, how? ________________________________________________
42.
L
M
H
42.
Have you received counseling on HIV (AIDS) in pregnancy?
Yes
No
43.
L
M
H
43.
Tell us what you know about and want to learn about:
Already
Like to know
Already know
Like to know
knows
Child Care
Breastfeeding
Hospital Tour
Infant Feeding
Labor & Delivery
Baby Care
Sexual Abuse
Exercise
Circumcision
Stop Smoking
Substance Abuse
Domestic Violence
How your Baby Grows
Sexually Transmitted Disease
Making Children Behave
Body Changes During
Pregnancy
Car Seat Safety
Other _____________________
Signs of Preterm Labor
44.
a. How do you learn things best? (please check all that apply)
44.
L
M
H
read
watch video
talk-one to-one
go to class
pictures or diagrams
demonstration
other ____________________________________________________________________________
b. Do you have any problems with hearing, seeing, or depression that will make it hard for you
to learn new things?
Yes
No
If yes, explain? ____________________________________________________________________
45.
L
M
H
45.
a. Will you have any problems coming to prenatal classes?
Yes
No
If yes, explain? ____________________________________________________________________
b. Who can come to prenatal classes with you?
46.
46.
List one or two things (goals) you would like to work on during this pregnancy.
L
M
H
1.
__________________________________________________________________________
2.
__________________________________________________________________________
47.
When was the last time that you went to the dentist? ________________________________________
47.
L M H
COMPREHENSIVE PERINATAL SERVICES PROGRAM
INITIAL PERINATAL RISK ASSESSMENT
Assessment Tool Completed by:
Name _________________________________
Title ______________________________________
Date ________________
Time spent in minutes: ___________________
Assessment Reviewed by:
Name (OB) _______________________________
Title ______________________________________
Date ________________
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