Family Road Healthy Start Preliminary Risk Screening Tool

Name(Required)

First Last

Do you have children?(Required)

How many?(Required)

Can you list their ages?

Have you had any:

Miscarriages

Abortions

Stillbirths

Low Birth Weight Births (> 5lbs 6oz)

Preterm Births (37 weeks)

Infant Death (28 days or less)

Have you previously been treated for any of the conditions below or are you currently being treated for any of these conditions:

Previously Received Treatment

Diabetes

High Blood Pressure

Sexually Transmitted Diseases/Infections

Mental Health Counseling

High Risk Prenatal Care

HIV/AIDS

Depression

Diagnosis of psychiatric condition

(Please Select All that Apply)

Currently Received Treatment

Diabetes

High Blood Pressure

Sexually Transmitted Diseases/Infections

Mental Health Counseling

High Risk Prenatal Care

HIV/AIDS

Depression

Diagnosis of psychiatric condition

(Please Select All that Apply)

If you could change the timing of this pregnancy, would you want the pregnancy to be ..... ?(Required)

Has your current partner ever hit or threatened you ?(Required)

Are you homeless?(Required)

In the last month, have you

Smoked Cigarettes

Drank alcohol

Used drugs

(Please select all the apply)

Name

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Comments

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Family Road Healthy Start Preliminary Risk Screening Tool

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