PRENATAL CARE COORDINATION INITIAL ASSESSMENT

Instructions available in the Prenatal Care Coordination Operational Guidelines. Bold / Shaded areas MAY indicate High Risk Factors

1. PNCC Agency: / 2. MCO Anthem MHS MDwise
1a. PNCC Address: / 2a. MCO Contact Person:
1b. Contact Person: / 2b. Phone: / 2c. Fax:
1c. Phone: / 1d. Fax: / Code: H1000 / 2d. MCO Pre-Notification #
3. Date 1st Encounter: / 3a. Type: HV Clinic
Office Other / 4. Date 2nd Encounter / 4a. Type: HV Clinic
Office Other
SECTION I — GENERAL INFORMATION - membeR / 5a. RID
5. Name:
(Last, First, MI, Maiden)
6. Race American Indian Asian Black
Hawaiian / Pacific Islander White Other / 7. Date of Birth (mm/dd/yyyy)
8. Age: / If <16 – CPS referral
If <18 – Guardian info / 9. Education:
<10 <12 12/ged 12+ / 10. Ethnicity
Hispanic
Non-Hispanic / 11. Primary language spoken:
English Spanish *Other
*list:
12. Address: / 13. Marital Status: Single Married
Separated Divorced
14. County: / 15. Phone: / 16. Email address:
17. Best way to contact participant? / 17a. Best time to contact participant?
18. Guardian Name: / 18a. relationship:
19. Address:
20. Phone 1: / 20a. Phone 2:
Emergency Contact Information: / 21. Name:
22. Address: / 22a. Phone:
23. Medical Provider or Clinic, Physician name, phone and fax numbers:
Does not have a medical provider
24. Insurance Status
Private Self Medicaid PE Pkg E Approved Pending None
section ii – current pregnancy
25. Last Menstrual Period? / 26. Estimated date of Conception? / 27. EDC:
28. When was your first medical appointment for prenatal care (mm/dd/yy) / 29. I have not seen anyone yet.
30. An appointment set for (mm/dd/yyyy) / 31. Two (2) or more visits to ER during this pregnancy?
Yes No
32. If you could change the timing of this pregnancy, when would you want it? Earlier No Change Later not at all
33. Are you pregnant with more than one baby Yes No Don’t Know / 33a. If yes, how many?
34. How many times have you been to a dentist or dental clinic in the last two years? / not at all
35. Do you plan to breastfeed? Yes No Not sure / 36. HIV test during last pregnancy? Yes No
35a. How did you come to this decision? Family Friend Myself / 36a. HIV test during this pregnancy? Yes No
section iiI – pregnancy HISTORY / 37. First Pregnancy (If First Pregnancy SKIP Section III)
38. How many times have you been pregnant before? / 39. Number of full term babies
40. Number of babies born more than 3 weeks early / 41. Number of pregnancy loss at less than 20 weeks
42. Number of pregnancy loss at 20 or more weeks / 43. Number of living children
44. Number of babies weighing less than 5 ½ lbs at birth / 45. Number of babies weighing more than 9 lbs at birth
46. Number of babies weighing less than 3 ½ lbs at birth / 47. Date and outcome of last Pregnancy:
Live Birth Miscarriage Stillbirth Abortion
SECTION IV-nutrition / weight / bmi
48. Since you have been pregnant how has your eating habits changed? Changed, Describe ______No Change
49. During the past month, did you miss any meals, not eat when you were hungry, or use a food pantry because there was not enough food or money to buy food? Yes No
50. Indicate any problems? Appetite? Indigestion? Nausea/Vomiting? Diarrhea? Constipation?
Describe:
51. Are there any foods that you are allergic to or avoid eating? Yes, please list______No
52. Are you taking any vitamin/mineral/dietary/botanical supplements? Yes, please list ______No
53. Have you eaten or had any cravings for non-food items? Yes, please list ______No
54. Cultural preferences affecting nutrition Yes, please list ______No
55. History of weight loss surgery? Yes No / 56. History of Eating Disorder? Yes No
57. Mother’s birth weight (list mother’s weight when she was born) Example: 5 lbs, 2 oz ______lbs. ______oz.
57a. Less than 5lbs 8 oz 57b. More than 9lbs 57c. Unknown
58. Diet Intake/Physical Activity Record --- Check all that apply (Also see www.myPyramid.com) / Diet Assessment/Evaluation
a. How often do you eat foods from the dairy group?
(3 or more times a day - ex. milk, yogurt, cheese, cottage cheese) Yes No
b. How often do you eat fruit?
(More than 4 times a day - ex. apples, bananas, oranges, grapes, etc) Yes No
c. How often do you eat vegetables?
(5 or more times a day - ex: broccoli, spinach, greens, salad, V-8 juice, etc) Yes No
d. How often do you eat foods from the meat & beans group?
(More than 3 times a day - ex: meats, fish, eggs, peanut butter) Yes No
e. How often do you eat foods from the grains group? Yes No
(6 or more times a day - ex: cereal, rice, pasta, bread, tortillas, pita bread, bagels, crackers)
f. How often do you drink a glass or bottle of water? (8 or more times a day) Yes No
g. How often do you drink sweetened drinks?
(More than 1 per day - ex: pop, Kool Aid + sugar, Snapple, energy drinks) Yes No
h. How often do you drink coffee, tea, cocoa, colas or eat chocolate?
(More than 3 beverages a day-includes energy & diet drinks) Yes No
i. How often do you eat bakery goods or snack items?
(More than 5 times a day - ex: doughnuts, pop tarts, cookies, chips, candy) Yes No
j. Do you eat luncheon meats or soft cheeses?
(Ex: consumes lunch/deli meats, feta, brie, non-pasteurized cheeses) Yes No
k. How often do you eat out or get carry-out?
(More than 10 times a week - ex: Fast food, Dine-in, Grab & Go) Yes No
l. How much time do you spend in physical activity? Yes No
(30  minutes or more a day - ex: walking/walk to work, dancing, running, swimming) / a. Inadequate diary intake
b. Inadequate fruit intake
c. Inadequate vegetable intake
d. Inadequate meat/bean intake
e. Inadequate grain intake
f. Inadequate fluid intake
g. Excess intake of sweetened drinks
h. Excess intake of caffeine
i. Excess intake of high-energy (calorie) or high-fat foods/ drinks
j. Food Safety Issues
k. Excess intake of convenience foods, and foods prepared away from home
l. Inadequate physical activity
59. On a scale of 0 to 10, how would you feel about making ANY changes to your eating habits or lifestyle?
Circle one: 0 1 2 3 4 5 6 7 8 9 10
60. Do you have any questions or concerns about your weight or eating habits?
Yes, please indicate in the narrative notes section No
61. Are you receiving nutrition services from WIC? / Yes / No / Appt Scheduled / Refused
62. Weight Before Pregnancy / 62a. Current Weight / 62b. Height / 63. Pre-Pregnancy BMI
Use this link to calculate BMI http://www.nhlbisupport.com/bmi/
63a. *If your BMI is <18.5 there is a concern your baby may have some health problem. It is recommended that you gain 28-40 pounds.
63b. *If you BMI is 18.5 to 24.9, it is recommended that you gain between 25-35 pounds during your pregnancy
63c. *If your BMI is 25.0 to 29.9, it is recommended that you gain between 15-25 pounds.
63d. *If your BMI is 30.0, there is a concern you or your baby may have health problems during pregnancy, labor or delivery. It is
recommended that you gain between 11 – 20 pounds.
section v – PREGNANCY concerns
64. Do you have or have you ever had any of the following treatment conditions? (Check all that apply)
Active Cancer
Active Hepatitis B or C
ADHD
Anemia
Asthma daily meds
Anxiety
Bipolar
Boderline Personality
Cardiac conditions / Chlamydia, gonorrhea,
genital herpes
Clinical depression
Diabetes
Gestational Diabetes
Group B Strep
HELLP
HIV/AIDS
Hypertension / Incompetent cervix
Intellectual disability
Lupus
Oligo or poly hydramnios
On methadone
Physical disability
Placental Problems
(including Previa)
/ Pre-eclampsia/Eclampsia
Preterm labor PROM
Repeat UTI/ Pyelonephritis
Rh Negative Seizures/epilepsy on meds
Thyroid disease on meds
Other illness, infections, or conditions requiring medical (Describe)
65. Do you have dental pain or bleeding gums when you eat or brush your teeth? (Periodontal problems) Yes No
66. Have you had any bleeding or cramping? (Describe) Yes No
SECTION VI– SUBSTANCE USE
67. In the past year, have you ever drank, smoked or used drugs more than you meant to? Yes No
68. Have you felt you needed to cut back on your drinking, smoking or drug use in the past year? Yes No
69. Did either of your parents have a problem with alcohol or drugs? Yes No
70. Do any of your friends (peers) have a problem with alcohol or drugs? Yes No
71. Does your partner have a problem with alcohol or drugs? Yes No
72. Have you had a problem with alcohol or drugs in the past? Yes No
73. Have you smoked any cigarettes, used alcohol or any drugs in this pregnancy? Yes No
74. Does anyone in your household smoke cigarettes? Yes No
75. Stage of change Pre-contemplation Contemplation Preparation Action other
75a. Do you think you can stop smoking in the next thirty days? Yes No
75b. Do you think you can stop using alcohol in the next thirty days? Yes No
75c. Do you think you can stop or cut down on drug use in the next 30 days? Yes No
SECTION VII – PSYCHOSOCIAL
76. In the past year have you been hit, slapped, kicked, or otherwise physically hurt by someone? Yes No
77. Since you’ve been pregnant have you been hit, slapped, kicked or otherwise physically hurt by someone? Yes No
78. Within the last year has anyone made you do something sexual that you did not want to? Yes No
79. Are you afraid of your partner or anyone else? Yes No
80. Does your partner ever humiliate you? Put you down in public? Keep you from seeing friends or family? Yes No
81. Have you ever been physically, sexually, emotionally, or verbally abused by your partner or someone close to you? Yes No
82. Do you feel safe in your neighborhood? Yes No
83. Have you had any problems with housing in the past three months? Yes No
84. Have you ever been homeless? Yes No
85. Do you have problems with utilities, appliances, bedding, furniture, food, clothing, or other things? Yes No
86. Do you have transportation, childcare, or other problems that prevent you from keeping your health care or social services
appointments? 86a. transportation 86b. childcare 86c. other Yes No
87. How would you rate your stress level? High Medium None
88. Lately, have you felt sad or down, have problems sleeping or eating, are unable to enjoy things most of the day, nearly every day?
Yes No
89. Have you had problems with depression or received counseling or medication for depression, anxiety or other mental health
concerns? Yes No
90. Have you experienced any of these major changes/stressors in your life in the past year? (Check all that apply)
Divorce Homeless Unemployed/Lost job Child(ren) removed from your home Death of a family member
Recent miscarriage/loss Been in jail/arrested Other, describe:______
91. Do you have family living close by? Yes No 92. Is the father of this baby involved? Yes No
93. Do you live alone? Yes No 94. Do you have a reliable phone? Yes No
95. How many people can you count on when you need help? 0 1-2 3+
96. Do you feel your support at this time in your pregnancy is Enough Not enough
97. Is there one person that is always there for you? Yes No
(name/relationship)______
98. Which of these things worries you a lot? Check all that apply
Money problems My own substance use (list) ______
My job My partner’s substance use Labor and delivery
My partner’s job/ unemployment My partner is in jail Caring for this baby
My relationship with my partner My partner did not want this pregnancy Caring for my other children
99. What worries you the most?
100. What do you do to deal with your problems?
101. What topics would you like to learn more about? (Check all that apply.)
How the baby is growing Labor and delivery Getting health care for you and you baby Managing stress Nutrition during pregnancy Breastfeeding Effects of alcohol on the baby Caring for your newborn
Family Planning/birth control How to stop smoking Managing the discomforts of pregnancy
Other (describe)
SECTION VII – NARRATIVE NOTES (include additional pages if necessary)
section IX INDIVIDUALIZED CARE PLAN
PROBLEM / GOALS / PLAN
SECTION X Referrals
date / Adoption / date / referral / date / referral
Alcohol / Drug Abuse Services / Food/Clothing Pantry / Rent / Utility Assistance
Education / GED / Human Services / Shelter, Homeless/ violence
Child Birth Education / Lactation Consultant / Social Services
DFC / Food Stamps/ TANF / Medicaid / Smoking Cessation
Domestic Violence Program / Mental Health / Township trustee
Employment / Nutritionist / FNP / Transportation
Family Support/ parenting / Prenatal Care / WIC
Other/ / Other/ / Other/
SECTION XI Education topics
DATE / EDUCATION / DATE / EDUCATION / DATE / EDUCATION
Breastfeeding / Drug/alcohol cessation / Preterm Labor
Community Resources / Lessons Learned / Smoking cessation
Coping Skills / Normal discomforts / Secondhand smoke
Dental health / Nutrition / std/ signs of infection
Domestic Violence prevent / Prenatal Care / Vitamins/ Folic acid / iron
HIV risks/testing / Prenatal weight gain / Warning signs of pregnancy
Financial Planning / Other/ / Other/
section XiI– to be completed by health professional
Is the participant eligible for Medicaid-Reimbursed Prenatal Care Coordination Services at this time? (date)______
Yes, based on risk factors No, not found to be High Risk No, undocumented immigrant
First Encounter / SECOND Encounter
Signature – Staff Completing Assessment / Date / Signature – Staff Completing Assessment / Date
signature – Qualified Health Professional / Date
(If different than above) / signature – Qualified Health Professional / Date