Combined Second Trimester Pregnancy Reassessment Form
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1COMPREHENSIVE PERINATAL SERVICES PROGRAM
nd
COMBINED 2
TRIMESTER REASSESSMENT
Client Name __________________________ DOB ________________________ DATE _______________
Substance Abuse:
ANTHROPOMETRIC
WT. GRID PLOTTED
12.
Are you smoking at all?
Wt. this visit: _______________
Weeks Gestation: ____________
Y
N
Gain Since Last Visit: ______________
Total Wt. Gain ________
If YES, how many cigarettes per day? __________________
Comment: ______________________________________________
13.
How often do you drink beer, wine, or liquor? ___________
________________________________________________________
14.
What drugs have you used since becoming pregnant?
_________________________________________________
BIOCHEMICAL
Labor and Delivery
Blood
Date Collected: _____________
15.
Have you had a hospital tour
Y
N
Hemoglobin:
H
L
Hematocrit:
H
L
16.
Do you need information about what will
MCV:
H
L
Albumin:
H
L
happen during labor and delivery?
Y
N
Glucose:
H
L
GTT
H
L
Urine
Date Collected: __________________
Health Education Goals:
Glucose:
+
-
Protein:
+
-
Ketones:
+
-
CURRENT CLINICAL
PSYCHOSOCIAL
Blood Pressure: ______/______
Edema: _______________
17.
Where are you living right now? ______________________
1.
Schedule test procedures?
18.
How many people are living with you? _________________
Y
N
19.
If you are worried about something, who do you talk to? ___
If YES, please list: __________________________________
_________________________________________________
20.
Do you have :
2.
Taking prenatal vitamins
electricity
hot water
telephone
Y
N
Iron?
transportation
heating
refrigerator
stove/oven
Y
N
21.
Are you able to buy enough food?
Y
N
3.
Taking new medications or herbs?
Y
N
22.
Are you able to pay rent?
Y
N
If YES, please explain: _______________________________
23.
Are you able to pay other bills?
Y
N
24.
How do you feel about this pregnancy? _________________
4.
Significant changes since last assessment?
Y
N
25.
Since becoming pregnant, have you had? ( √ if yes)
If YES, please explain: _______________________________
trouble sleeping
sadness
worried feelings
crying
depression
sadness
Clinical Update from previous visit:_____________________
none
other ________________________
__________________________________________________
26.
Since becoming pregnant, have you been slapped, hit, or
otherwise hurt by someone? If yes by whom? ____________
NUTRITION
5.
Have your eating habits changed since
REFERRALS:
your last assessment?
Y
N
Date enrolled _______________
WIC
If YES, explain?
Appointment Date ____________
Date attended _______________
Car seat class
Dietary Assessment
24 hour recall completed
Dietary Goals/Comments:
Other referrals
1) ________________
Date __________
2) ________________
Date __________
MATERIALS GIVEN:
Infant Feeding
Family Planning
Infant Feeding
6.
How do you plan to feed your baby?
other ________________
___________________
Breast
Bottle
Both
Not sure
7.
Have you breastfed a baby before?
Y
N
ASSESSMENT SUMMARY:
If YES, how long did you breastfeed? ___________________
HEALTH EDUCATION
8.
Do you have an infant car seat?
R/A Completed By:
Y
N
9.
Do you have a doctor for the baby?
Y
N
Time spent in minutes: Nutrition_______________
10.
Do you know what birth control you will
Health Education_________
use?
Y
N
Psychosocial____________
11.
Have you receive counseling on HIV
(AIDS)?
Y
N
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