Initial Perinatal Risk Assessment Form
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4COMPREHENSIVE 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 __________
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M
H
English
Spanish
2.
2.
What languages do you read?
Other __________
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M
H
English
Spanish
3.
3.
How many years of school have you finished? ____________years
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M
H
4.
Do you have a job?
What kind of work? _________________
4.
Yes
No
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M
H
5.
Does your partner have a job?
What kind of work? _________________
5.
Yes
No
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M
H
6.
6.
Are you on a special diet?
If you are on a special diet, what kind?
Yes
No
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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.
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If yes, what _______________________________________________
Yes
No
9.
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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)? __________________________
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M
H
11.
Do you have
11.
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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.
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M
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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.
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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.
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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: __________________________
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