Initial Perinatal Risk Assessment Form Page 2
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4COMPREHENSIVE PERINATAL SERVICES PROGRAM
INITIAL RISK ASSESSMENT
15.
How do you plan to feed your baby?
15.
Breast
Bottle
Both
not sure
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16.
Have you breastfed a baby before?
16.
Yes
No
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17.
a. Where are you living right now?
17.
House
Apartment
Motel
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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.
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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.
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19.
If you are worried about something, who do you talk to? _______________________________________
husband/partner
parents
grandparents
other relatives
friend
other person ______________________________________________
20.
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20.
Do you have (√
if yes)
electricity
hot water
refrigerator
stove or oven
transportation
a telephone
heating
21.
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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.
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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.
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24.
Do you have an infant car seat?
Yes
No
24.
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25.
Do you use your car seat belt?
Yes
No
25.
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26.
Was your pregnancy planned?
Yes
No
26.
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27.
How does the baby’s father feel about this pregnancy?
27.
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doesn’t care
doesn’t know
angry
happy
sad
other ________
28.
How do you feel about this pregnancy?
28.
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don’t care
angry
happy
sad
other _______
29.
Have you ever had any of the following?
29.
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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.
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you would like supported?
Yes
No
If yes, please explain ____________________________________________________________________
31.
Since becoming pregnant, which of the following have you had? (√
if yes)
31.
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problem sleeping
excessive worrying
crying
depression
sadness
none
other ___________________________________
32.
Are you taking medicine for your nerves?
32.
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Name of Medicine ________________________________
Yes
No
33.
What two problems in your life cause you the most trouble?
33.
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1. _____________________________________
2. ______________________________________
34.
Have you ever thought about, planned, or tried to hurt yourself?
Yes
No
34.
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35.
Have you ever thought about, planned, or tried to hurt someone else?
Yes
No
35.
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36.
In the past year, have you been slapped, hit, kicked, or otherwise physically hurt by
36.
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someone?
Yes
No
By whom? (check all that apply)
partner/husband
ex-husband
parent
step-parent
stranger
brother/sister
# times hurt ____________
other _____________________
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