Form Dh 3134, 04/08 - Help Your Baby Have A Healthy Start In Life!
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1Help your baby have a healthy start in life!
Please answer the following questions to find out if anything in your life could affect your health
or your baby’s health. Your answers are confidential. You may qualify for free services from the
Healthy Start Program or the Healthy Families Program, no matter what your income level is!
(Please complete in ink.)*
Today’s Date: _______________________
YES NO
YES NO
YES NO
YES NO
11. What race are you? Check one or more.
1. Have you graduated from high school or
1 1 1 1
White
Black
Other ___________________
received a GED?
3 3 3 3
12 . In the last month, how many alcoholic drinks did you
2. Are you married now?
1 1 1 1
have per week?
3. Are there any children at home younger
___________ drinks
did not drink
1 1 1 1
than 5 years old?
13. In the last month, how many cigarettes did you
4. Are there any children at home with
smoke a day? (a pack has 20 cigarettes)
medical or special needs?
___________ cigarettes
did not smoke
1 1 1 1
5. Is this a good time for you to be pregnant?
14 . Thinking back to just before you got pregnant, did you
want to be…….?
6. In the last month, have you felt down,
1 1 1 1
pregnant now
pregnant later
not pregnant
depressed or hopeless?
1 1 1 1
15 . Is this your first pregnancy?
7. In the last month, have you felt alone
Yes
No If no, give date your last pregnancy ended:
when facing problems?
2 2 2 2
Date: (month/year)_____________
8. Have you ever received mental health
services or counseling?
16. Please mark any of the following that have happened.
Had a baby that was not born alive
9. In the last year, has someone you know
3 3 3 3
tried to hurt you or threaten you?
Had a baby born 3 weeks or more before due date
3 3 3 3
Had a baby that weighed less than 5 pounds, 8 ounces
10. Do you have trouble paying your bills?
3 3 3 3
None of the above
Name: First
Last
M.I.
Social Security Number:
Date of Birth (mo/day/yr):
17. Age:
<
18
1 1 1 1
Street address (apartment complex name/number):
County:
City:
State:
Zip Code:
Prenatal Care covered by:
Best time to contact me:
Phone #1
____________________________
Medicaid
Private Insurance ___________________
No Insurance
Other _____________________________
Phone #2
____________________________
I authorize the exchange of my health information between the Healthy Start Program, Healthy Start Providers, Healthy Start Coalitions,
Healthy Families Florida, WIC, Florida Department of Health, and my health care providers for the purposes of providing services, paying for
services, improving quality of services or program eligibility. This authorization remains in effect until revoked in writing by me.
Patient Signature:
_________________________________________________
Date: _________________________________
Please initial: ________ Yes ________
No
I also authorize specific health information to be exchanged as described above, which
includes any of my mental health, TB, alcohol/drug abuse, STD, or HIV/AIDS information.
If you do not want to participate in the screening process, please complete the patient information section only and sign below:
Signature: ______________________________________________________________
Date: _______________________________________
EDD (mo/day/yr):
LMP (mo/day/yr):
18. Pre-Pregnancy:
<
19.8
19.8
19.8
19.8
1 1 1 1
>
35.0
35.0
35.0
35.0
Wt: _______lbs. Height: _____ft. _____in. BMI: _________
2 2 2 2
Provider’s Name:
Provider’s ID:
19. Pregnancy Interval Less Than 18 Months?
N/A
No
Yes
Yes
Yes
Yes
1 1 1 1
20. Trimester at 1st Prenatal Visit? ______________________
2nd
2nd
2nd
2nd
1 1 1 1
Provider’s Phone Number:
Provider’s County:
21. Does patient have an illness that requires ongoing medical care?
Yes
Yes
Yes
Yes
Specify illness: _____________________________
No
2 2 2 2
Healthy Start
Check One:
Referred to Healthy Start. If score <6, specify:_______________________________
Screening Score: _________
_________
_________
_________
Not Referred to Healthy Start.
Provider’s/Interviewer’s Signature and Title __________________________________________________________ Date (mo/day/yr)___________________
DH 3134, 04/08, stock number 5744-100-3134-7
Distribution of copies:
WHITE & YELLOW—County Health Department in county where screening occurred
PINK—Retained in patient’s record
GREEN—Patient’s Copy
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