Ccnc Pregnancy Home Risk Screening Form - 1st Ob Visit printable pdf download

CCNC Pregnancy Home Risk Screening Form

Practice Name: ____________________________________

First name: __________ MI___ Last name:______________ Medicaid ID#:______________ Today’s date: __/__/____

EDC: __/__/____ By what criteria:  LMP  1

trimester U/S  2

 Other:_______________

trimester U/S

Height: ________

Pre-pregnancy weight: __________

Gravidity: _____

Parity: ___ ___ ___ ___

 Medicaid

 None

 Other: ________________

Insurance type:

Date of birth: __/__/____

 No changes

CURRENT PREGNANCY

Practice phone no:________________

*Multifetal gestation

since last screen



Next prenatal appt: __/__/_____

*Fetal complications:



OBSTETRIC HISTORY

Fetal anomaly



Fetal chromosomal abnormality



Intrauterine growth restriction (IUGR)

*Preterm birth (<37 completed weeks)



Oligohydramnios

Gestational age(s) of previous preterm birth(s):



Polyhydramnios



______weeks, ______weeks, ______weeks

Other: ____________________



At least one spontaneous preterm labor



*Chronic condition which may complicate



and/or rupture of the membranes

pregnancy:

If this is a singleton gestation, this patient

Diabetes



is eligible for 17P treatment.

Hypertension



Asthma



*Low birth weight (<2500g)



Mental illness



*Very low birth weight (<1500g)



HIV



Seizure disorder



Fetal death >20 weeks



Renal disease



Neonatal death (within first 28 days of life)

Systemic lupus erythematosus



Other(s): _____________________



Second trimester pregnancy loss



*Current use of drugs or alcohol/recent drug



use or heavy alcohol use (month prior to

Three or more first trimester pregnancy losses



learning of pregnancy)

Cervical insufficiency



*Late entry into prenatal care (>14 weeks)



*Hospital utilization in the antepartum period

Gestational diabetes



*Missed 2+ prenatal appointments



Postpartum depression



Cervical insufficiency



Gestational diabetes

Hypertensive disorders of pregnancy



Vaginal bleeding in 2

trimester

Eclampsia



Hypertensive disorders of pregnancy

Preeclampsia



Eclampsia



Gestational hypertension



Preeclampsia



HELLP syndrome



Gestational hypertension



HELLP syndrome



*Provider requests pregnancy care



Short interpregnancy interval (<12 months



management

between last live birth and current pregnancy)

Reason(s):_______________________________

Current sexually transmitted infection



_______________________________________

Recurrent urinary tract infections (>2 in past 6



_______________________________________

months, >5 in past 2 years)

_______________________________________

Communication barriers:



_______

Literacy



: __________________

Provider comments/notes

Disability



_______________________________________

Explain: ___________________________

_______________________________________

Non-English speaking



_______________________________________

Primary language: ___________________

_______________________________________

Items marked with a * will trigger follow-up by a

_______________________________________

pregnancy care manager.

Name of person completing form: ___________________________________ Signature: _________________________________

Ccnc Pregnancy Home Risk Screening Form - 1st Ob Visit

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