Prenatal Educator Health Visit Form printable pdf download

SETA Early Head Start

Prenatal EHS Educator Health Visit

Date _______________

Initial Visit _____

Regular Visit _____

Referral _____

Name of Mother to Be ______________________________________________________

Age ___________

Address _____________________________ City _______________ Zip __________ Phone # ___________

Name of Father to Be _______________________________________________________

Age __________

Address _____________________________ City _______________ Zip __________ Phone # ___________

Due Date ____________ Hospital _________________ Obstetrician ___________ Pediatrician ___________

Staff Present _______________________________________________________________________________

Other Individuals Present _____________________________________________________________________

INFORMATION DISCUSSED

Trimester (Months 1, 2, & 3)

Trimester (Months 4, 5, & 6)

___ Importance or early and continuous prenatal care

___ Continue prenatal care

___ How client is feeling

___ Continue vitamins and folic acid

___ Father’s questions

___ Weight gain

___ Receiving WIC Services, if not, refer

___ Is baby kicking?

___ Vitamins and folic acid

___ Discomforts of pregnancy

___ Morning sickness

___ Signs of pre-term labor

___ Tobacco use, including 2

hand smoke

___ Sex during pregnancy

___ Drug use, illegal and over the counter

___ Domestic violence

___ Previous miscarriage

Trimester (Months 7, 8, & 9)

___ Types of delivery – vaginal or C-Section

___ Continue prenatal care

___ Infant car seat – correct positioning

___ Continue vitamins

___ Weight gain

___ Basic baby supplies

___ Diapers – cloth or disposable

___ Is baby kicking?

___ Feeding your baby – breast or bottle feeding?

___ Signs of labor

___ Timing of contractions

___ Who will help at home after the delivery?

___ Discuss discomforts

___ Where will baby sleep

___ Father’s questions

___ Postpartum visit

___ Tobacco use including 2

hand smoke

___ Sex after baby comes

___ Drug use, illegal and over the counter

___ Birth control methods

___ Delivery – hospital, birthing center or home

___ Postpartum baby blues

___ How to get to hospital

___ Choosing a pediatrician

___ Who will be with you?

___ Preparing the other children for the new baby

___ Packing your suitcase

White – Child’s File

Canary – Parent

Pink – Health Services

Distribution:

8/15

Revised

H/N Services G:\Master Forms\01 Numbered Forms Word Only\435 EHS Prenatal Educator Health Visit NCR.rtf

Prenatal Educator Health Visit Form

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