"Combined Post-partum Assessment Form - Comprehensive Perinatal Services Program" - San Bernardino County, California

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COMPREHENSIVE PERINATAL SERVICES PROGRAM
COMBINED POST-PARTUM ASSESSMENT
Client Name __________________________ DOB __________________ Delivery Date _______________ Date ________________
Infant Feeding (cont.)
ANTHROPOMETRIC
WT. GRID PLOTTED
12.
If you are Bottlefeeding,:
Height _______________
Desirable Body Weight: ____________
a.
How often does your baby get a bottle? ____________
Weight this Visit: ____________
Weeks Post-Partum__________
b.
How much does your baby drink at a feeding? _______
Comment: ______________________________________________
c.
√ the one(s) you use:
________________________________________________________
Concentrated
Formula
BIOCHEMICAL
Blood
Date Collected: _____________
Powdered Formula
Ready to
Hemoglobin:
H
L
Hematocrit:
H
L
Drink Formula
Glucose:
H
L
Albumin:
H
L
d.
What else do you give your baby?
Blood Pressure:
/
(circle)
GDM
PIH
Juice
Cereal
Sugar Water
Baby Food
Other ______________________
CLINICAL-Outcome of Pregnancy
HEALTH EDUCATION
13.
Do you have any questions about your baby’s
care?
Date of Birth: _____________
Gestational Age:_____________
Y
N
Birth Weight: _____________
Birth Length: _______________
If YES, please explain: ____________________________
Delivery
_______________________________________________
Vaginal
C-section
14.
Which method of Birth Control are you currently using:
Pregnancy Outcome/Complications:
Birth Control Pills
Diaphragm
Condoms
Norplant
Depo-Provera (shots)
Other ________
Maternal
15.
Would you like information about Birth
1.
Have you had your post-partum check up?
Y
N
Control?
Y
N
If NO, when is it scheduled? _________________________
16.
Do you have an infant car seat?
Y
N
2.
Have you had any problems since delivery?
Y
N
If YES, do you always use it? _________________
If YES, please explain. _______________________________
17.
Do you exercise 3 or more times a week?
__________________________________________________
18.
Do you smoke?
Y
N
If YES, how many cigarettes per day? _______
Infant
19.
Do you live with someone who smokes ?
3.
Has you baby seen the doctor?
Y
N
20.
How often do you drink beer, wine, or liquor? ____________
If NO, when is the visit scheduled?
21
What drugs have you used since the birth of
your baby?
NUTRITION
PSYCHOSOCIAL
Dietary Assessment
22.
Since your baby’s birth, which of the following have you
24 hour recall completed
had?
4.
Are you on a special diet?
Y
N
trouble sleeping
sadness
worried feelings
If YES, what diet? __________________________________
5.
Are you allergic to any foods, or do you avoid eating any
crying
depression
other _____________
foods?
23.
If you are worried about something, who do you talk to?
If YES, what foods? ________________________________
___________________________
6.
Which of the following do you take?
24.
Are you and your baby safe in your home?
Y
N
Prenatal Vitamins
Iron Pills
25.
Have you ever planned or tried to hurt
yourself?
Other Vitamins/Mineral
Herbs
Y
N
26.
Have you ever planned or tried to hurt
Antacids
Laxatives
Other Medications
someone?
7.
How many cups, glasses or cans of these do you drink daily?
Y
N
Water _____
Milk _____
Juice _____
Coffee ____
27.
Since the birth of your baby, have you been slapped, hit,
Tea ____
Soda ____
Diet Soda ___
Punch/Kool Aid
kicked or otherwise physically hurt by someone?
Y
N
8.
How many times a day do you usually eat? _________
If YES, by whom? ____________________________
9
Which of the following do you have?
28.
Do you have:
electricity
hot water
telephone
Refrigerator
Stove/Oven
Hot Plate
transportation
heating
29.
Are you able to buy enough food?
Y
N
30.
Are you able to pay your rent?
Y
N
31.
Are you able to pay your other bills?
Y
N
Infant Feeding
Date enrolled _______
Appt. Date _________
WIC Referral
10.
How many diapers does your baby wet in a day? ________
Other referrals:
11.
If you are Breastfeeding:
1)
_________________________
Date ________________
a) how many times in 24 hours do you nurse? __________
2)
_________________________
Date ________________
b) how long does your baby nurse each time? __________
Material Given:
Family Planning
Infant Feeding
other ___________________
other ____________________
Assessment completed by: _________________________
Time spent in minutes: Nutrition____________________
Health Education_____________
Psychosocial ________________
COMPREHENSIVE PERINATAL SERVICES PROGRAM
COMBINED POST-PARTUM ASSESSMENT
Client Name __________________________ DOB __________________ Delivery Date _______________ Date ________________
Infant Feeding (cont.)
ANTHROPOMETRIC
WT. GRID PLOTTED
12.
If you are Bottlefeeding,:
Height _______________
Desirable Body Weight: ____________
a.
How often does your baby get a bottle? ____________
Weight this Visit: ____________
Weeks Post-Partum__________
b.
How much does your baby drink at a feeding? _______
Comment: ______________________________________________
c.
√ the one(s) you use:
________________________________________________________
Concentrated
Formula
BIOCHEMICAL
Blood
Date Collected: _____________
Powdered Formula
Ready to
Hemoglobin:
H
L
Hematocrit:
H
L
Drink Formula
Glucose:
H
L
Albumin:
H
L
d.
What else do you give your baby?
Blood Pressure:
/
(circle)
GDM
PIH
Juice
Cereal
Sugar Water
Baby Food
Other ______________________
CLINICAL-Outcome of Pregnancy
HEALTH EDUCATION
13.
Do you have any questions about your baby’s
care?
Date of Birth: _____________
Gestational Age:_____________
Y
N
Birth Weight: _____________
Birth Length: _______________
If YES, please explain: ____________________________
Delivery
_______________________________________________
Vaginal
C-section
14.
Which method of Birth Control are you currently using:
Pregnancy Outcome/Complications:
Birth Control Pills
Diaphragm
Condoms
Norplant
Depo-Provera (shots)
Other ________
Maternal
15.
Would you like information about Birth
1.
Have you had your post-partum check up?
Y
N
Control?
Y
N
If NO, when is it scheduled? _________________________
16.
Do you have an infant car seat?
Y
N
2.
Have you had any problems since delivery?
Y
N
If YES, do you always use it? _________________
If YES, please explain. _______________________________
17.
Do you exercise 3 or more times a week?
__________________________________________________
18.
Do you smoke?
Y
N
If YES, how many cigarettes per day? _______
Infant
19.
Do you live with someone who smokes ?
3.
Has you baby seen the doctor?
Y
N
20.
How often do you drink beer, wine, or liquor? ____________
If NO, when is the visit scheduled?
21
What drugs have you used since the birth of
your baby?
NUTRITION
PSYCHOSOCIAL
Dietary Assessment
22.
Since your baby’s birth, which of the following have you
24 hour recall completed
had?
4.
Are you on a special diet?
Y
N
trouble sleeping
sadness
worried feelings
If YES, what diet? __________________________________
5.
Are you allergic to any foods, or do you avoid eating any
crying
depression
other _____________
foods?
23.
If you are worried about something, who do you talk to?
If YES, what foods? ________________________________
___________________________
6.
Which of the following do you take?
24.
Are you and your baby safe in your home?
Y
N
Prenatal Vitamins
Iron Pills
25.
Have you ever planned or tried to hurt
yourself?
Other Vitamins/Mineral
Herbs
Y
N
26.
Have you ever planned or tried to hurt
Antacids
Laxatives
Other Medications
someone?
7.
How many cups, glasses or cans of these do you drink daily?
Y
N
Water _____
Milk _____
Juice _____
Coffee ____
27.
Since the birth of your baby, have you been slapped, hit,
Tea ____
Soda ____
Diet Soda ___
Punch/Kool Aid
kicked or otherwise physically hurt by someone?
Y
N
8.
How many times a day do you usually eat? _________
If YES, by whom? ____________________________
9
Which of the following do you have?
28.
Do you have:
electricity
hot water
telephone
Refrigerator
Stove/Oven
Hot Plate
transportation
heating
29.
Are you able to buy enough food?
Y
N
30.
Are you able to pay your rent?
Y
N
31.
Are you able to pay your other bills?
Y
N
Infant Feeding
Date enrolled _______
Appt. Date _________
WIC Referral
10.
How many diapers does your baby wet in a day? ________
Other referrals:
11.
If you are Breastfeeding:
1)
_________________________
Date ________________
a) how many times in 24 hours do you nurse? __________
2)
_________________________
Date ________________
b) how long does your baby nurse each time? __________
Material Given:
Family Planning
Infant Feeding
other ___________________
other ____________________
Assessment completed by: _________________________
Time spent in minutes: Nutrition____________________
Health Education_____________
Psychosocial ________________