Prenatal Record for

  Date of Birth   Date                      Medical Record #

SCREENING FOR ALCOHOL ABUSE
TWEAK Test (Russell 1984)
TOLERANCE
T 		Can you hold more than 5 drinks?
WORRY
W 		Have close friends or relatives worried or complained about your drinking in the past year?
EYE-OPENER
E 		Do you sometimes take a drink in the morning when you first get up?
AMNESIA
A 		Has a friend or family member ever told you about things you said or did while you were drinking that you couldn't remember?
K/CUT DOWN
K 		Do you sometimes feel the need to cut down on your drinking?
A score of 2 or above places the woman in a risk category and requires further assessment Score

SMOKING
ASSESSMENT OF EXPOSURE DURING PREGNANCY
On average how many days per week do you smoke?
On an average day, how many cigarettes do you smoke?
How many days have you smoked 10 or more cigarettes in the last month?
What is the most cigarettes that you smoked on any one day during this pregnancy?

EXPOSURE PARAMETERS
(Cumulative Exposure)
Smoking Days =
   Estimates number of smoking days during this pregnancy
Percent of Days Exposed =
   Estimates days exposed during this pregnancy
Number of Cigarettes =
   Estimates cumulative number of cigarettes during pregnancy
Number of Packs =
   Estimates cumulative exposure in packs during pregnancy
ALCOHOL
ASSESSMENT OF EXPOSURE DURING PREGNANCY
On average how many days per week do you drink?
On an average drinking day how many drinks do you have?
How many days in the last month have you had 5 or more drinks?
What is the most you had to drink on any one day in the last month?
EXPOSURE PARAMETERS
(Cumulative Exposure)
Drinking Days =
    Estimates the number of drinking days during this pregnancy.
Percent of Days Exposed =
    Estimates days exposed during pregnancy.
Number of Binge Days =
    Estimates number of binge days (5 or more drinks in one day) during pregnancy.
Number of Drinks =
    Estimates cumulative number of drinks during pregnancy.
Ounces of Absolute Alcohol =
    Estimates cumulative absolute alcohol exposure during this pregnancy.
MATERNAL RISK SCORE

Age over 25 years
Unmarried, divorced, widow, living with partner
On ADFC, WC, Social Security or income < $16k
Poor diet
Smokes more than 1/2 pack per day
Heavy drinker (drinks 3 or more drinks / day for 3 or more days per week, or more than 5 drinks /day on 6 or more occasions
Uses inhalants, sniffs, huffs or illegal drugs
Drinks, but less than criteria for heavy drinker
Age first drunk less than 15 years
in treatment over three times
In treatment in last 12 months
Previous child with FAS / Partial, birth defect, or developmental disability
Previous child died
Children out of home (foster care or adopted)
       0:   None - Standard Prenatal Care
       5:   Low - Standard Prenatal Care
20-40:   Moderate - Standard Prenatal Care and Patient Education on FAS
45-50:   High - High-Risk Pregnancy. Alcohol-Drug Abuse Treatment
55-85:   Very High - High Risk Pregnancy. Inpatient Treatment
 Total

Provided by
Larry Burd, Ph.D. North Dakota Fetal Alcohol Syndrome Center
University of North Dakota School of Medicine and Health Sciences, 501 North Columbia Road, Box 9037, Grand Forks, ND 58203

PRENATAL CARE PLAN
The care plan for             from the data on   
TWEAK Screen Score      2 or more is positive
Maternal Risk Score          Recommendation   
Smoking
Days exposed to smoking   
Percent of pregnancy exposed   
Cumulative exposure during pregnancy     cigarettes
Cumulative packs during pregnancy     packs
Alcohol
Days exposed to alcohol   
Percent of pregnancy exposed   
Binge Days (5 or more drinks in a day)     binges
Cumulative exposure during pregnancy     drinks
MANAGEMENT PLAN
Alcohol use:

 _______counseled

 _______referred

 _______attended referral

 follow-up on_______
Smoking: _______counseled

 _______referred

 _______attended referral

 follow-up on_______
Drug use: _______counseled

 _______referred

 _______attended referral

 follow-up on_______
Abuse: _______counseled _______referred _______attended referral follow-up on_______
EFFECTS OF EXPOSURE REDUCTION
Smoking Alcohol
            Smoking Risk Reduction Goal
             Smoking Days per Week
             Cigarettes per Smoking Day

            Cumulative Exposure Prevented
             Smoking Days
             Cigarettes 		            Alcohol Risk Reduction Goal
             Drinking Days per Week
             Drinks per Drinking Day

            Cumulative Exposure Prevented
             Drinking Days
             Drinks