Infant Risk Screen

Fill out this form to see if your infant is at risk.

This is similar to the form that will be completed after delivery of your baby. When you agree to the Healthy Start infant risk screen, the hospital or birthing center staff will complete a form like this for your baby. To find out more, contact us.

Please answer the questions below and then click "Show My Score." We do not ask for any identifying information and do not keep the results. This is just for you.

# Question Answer Score
 1  Mother's age is less than 18 or unknown.  Yes |  No 
 2  Mother is over 18 and mother's education is less than 12th grade or unknown  Yes |  No 
 3  Mother's race is unknown, other than white, or multiple races selected  Yes |  No 
 4  Mother is not married  Yes |  No 
 5  The number of prenatal visits is zero, one or unknown  Yes |  No 
 6  Infant's birth weight is less than 2000 grams or less than four pounds, seven ounces  Yes |  No 
 7  Mother used tobacco during pregnancy and number of cigarettes per day is more than nine or unknown  Yes |  No 
 8  Mother used alcohol during pregnancy or alcohol use is unknown  Yes |  No 
 9  Abnormal conditions of the newborn include membran disease/RDS, or assisted ventilation required (for 30 minutes or more) or assisted ventilation required (for six hours or more)  Yes |  No 
 10  Infant has one or more congenital anomalies  Yes |  No 

 

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