Prenatal Risk Screen

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

If you are currently smoking, would you like help to quit?

This is not the form your obstetrician or nurse-midwife will complete. This is just for your information. You will need to fill out the form at your medical provider's office. 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.

Your age:
Your race: Black | White | Other
Are you married? Yes | No
Have you graduated from high school or received a GED? Yes | No
When you were born, did you weigh 5 1/2 pounds or less? Yes | No
Your weight before pregnancy: pounds
Your height: feet   inches
Is this your first pregnancy? Yes | No
If No, when did your last pregnancy end? (Include live birth, stillbirth, miscarriage, and abortion) (MM/YYYY)
Is your prenatal care covered by: Insurance/HMO
Medicaid
Other (Military, Indian Health, etc.)
No Coverage
Do you have any problems that prevent you from keeping your health care or
social service appointments?		 Yes | No
Have you moved more than three times in the last 12 months? Yes | No
Do you feel unsafe where you live? Yes | No
Do you or any member of your household go to bed hungry? Yes | No
In the last two months, have you used any form of tobacco? Yes | No
In the last two months, have you used drugs or alcohol (including beer, wine and mixed drinks)? Yes | No
In the last year, has anyone tried to hurt you? Yes | No
How do you rate your current stress level? Low | Medium | High
If you could change the timing of your pregnancy, would you want it Earlier
Later
Not at all
No change
Have you considered adoption for this pregnancy? Yes | No
Have you now, or have you ever had, problems with depression? Yes | No
Do you have a history of receiving mental health counseling? Yes | No
Is your partner unemployed? Yes | No | N/A
Did your last pregnancy result in any of the following?
  • Miscarriage
  • Stillbirth
  • Baby less than 5 1/2 pounds
  • Baby born more than three weeks early
  • Baby stayed in hospital after you went home
 Yes | No
Do you have any illness that requires continuing medical care? Yes | No
What trimester were you in when you first had a prenatal doctor visit? First | Second | Third

 

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