Pregnancy Health Assessment Pregnancy Health Assessment Form Please complete the form below if you're interested in joining our no-cost maternity Health & Wellness Program for expecting mothers, Healthy Expectations. After reviewing your completed form, a Community First Health Educator will reach out to you. Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Date of Birth (MM/DD/YYYY)* MM slash DD slash YYYY Member ID (Located on your Community First Member ID card - Example: A0101000001)* Height* FeetInches* InchesWeight* Do you have other children currently covered under a Community First health plan?* Yes No Please enter each child's name and date of birth.Child's Name First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Child's Name First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Child's Name First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Child's Name First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Child's Name First Last Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY How should we contact you?* Email Phone General Health StatusHow far along are you in your pregnancy? 1st Trimester (0-12 weeks) 2nd Trimester (13-27 weeks) 3rd Trimester (28-40 weeks) I don't know/I'm not sure What is your estimated due date? (MM/DD/YYYY) MM slash DD slash YYYY Have you established care with an obstetrical health care provider (OB/GYN)? Yes No Please enter the name of your Provider. Have you had your first prenatal appointment with your OB/GYN? Yes No What was the date of your first prenatal appointment? (MM/DD/YYY) MM slash DD slash YYYY Have you scheduled your next visit with your OB/GYN? Yes No Do you need assistance with scheduling an appointment or transportation? Yes No What is the date of your next scheduled prenatal appointment? (MM/DD/YYY) MM slash DD slash YYYY Clinical HistoryIs this your first pregnancy? Yes No Do you have a history of miscarriage(s) in the second trimester? Yes No Did you take any fertility drugs or receive any medical procedures to help you become pregnant? Yes No Prior to this pregnancy, were you ever diagnosed with any of the following chronic health conditions?Check all that apply. Arthritis Asthma Depression Diabetes Heart Condition (hypertension, heart disease, heart failure, arrhythmia, congenital defect) None I don't know/I'm not sure Current PregnancyHow many babies are you expecting this pregnancy? 0 1 2 3 4 or more I don't know/I'm not sure Are you aware of special precautions that you should be taking while pregnant? (i.e. not drinking alcohol or eating raw fish, avoiding second hand smoke, not lifting/moving heavy objects, etc.) Yes No I would like to learn more Substance UseHave you used/consumed any of the following substances during this pregnancy?Check all that apply. Alcohol Drugs Smoking None MedicationAre you currently taking a prescribed/recommended prenatal vitamin? Yes No Do you take any other prescription, over-the-counter, or herbal/supplement medications besides your prenatal vitamin? Yes No VaccinationsAre you up-to-date on your recommended vaccinations? Yes No I don't know/I'm not sure I choose not to receive vaccinations Mental Health StatusOver the past two weeks, how often have you felt down, depressed, or hopeless? Not at all Several days More than half of the days Nearly every day Over the past two weeks, how often have you experienced little interest or pleasure in doing things? Not at all Several days More than half of the days Nearly every day If you feel you need to speak with someone about your mental health, please contact your PCP and/or behavioral health provider or reach out to one of the organizations listed below. 24-hour Crisis Line: 800-316-9241 or 210-223-SAFE (7233) SAPD Public Safety Unit: 210-207-7273 Bexar County Sheriff: 210-335-6000 Poison Control: 800-222-1222 Members can also call 2-1-1 or visit 211texas.org to locate a Behavioral Health (BH) professional. Social Determinants of HealthWhere do you currently live? House/Apartment I do not have housing (homeless, staying with others, in a hotel, in a shelter) No I prefer not to answer this question What is the highest level of education you have completed? Less than a high school diploma High school diploma/GED More than a high school diploma/GED I prefer not to answer this question Do you need help getting food or going to the grocery store? Yes No I prefer not to answer this question Do you need help with transportation to places like work, medical appointments, or the grocery store? Yes No I prefer not to answer this question Self-ManagementDo you have any current concerns or questions about your pregnancy? Yes No Member Communication ConsentDo you consent for Community First to communicate information electronically through a secure system that is designed to keep your information safe. You will be notified via email or SMS text when there is secure information for you to review. The email or SMS text will provide a link that will take you to the secure site. After clicking on the link, you will be required to login to access your information.* Yes No Δ
