PRIOR TO PREGNANCY - RISK ASSESSMENT QUESTIONNAIRE
Enter name or ID
Enter Date of Birth
Enter the Medical Record Number
Enter Today's Date
(The information you provide above will not be saved in a database. There will not be a record of your name, date of birth or medical record number.)
We want to provide you with the best care possible.
Please complete this form to help us care for you.
What is your age?
Current Marital Status
: (Check one)
Married
Widowed
Single
Divorced
Your Race/Ethnicity:
(Check one)
African American
Native American
Hispanic
Asian
Other
Income:
(Check one)
TANF
WIC
Social Security
Less than $16,000/yr
Your Education:
(Check one)
Graduated 8th Grade
GED
High School
High School Graduate
College
College Graduate
Graduate Education
How is your diet:
(Check one)
Good
Needs Improvement
Poor
Smoking:
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 last month?
What is the most cigarettes you smoked on any one day during this pregnancy?
Current Drinking Patterns :
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 day in the last month?
Alcohol Use History :
How old were you when you first used alcohol?
How old were you when you were first drunk?
How many years have you been drinking?
Total times in drug or alcohol treatment in your life time
Have you been in alcohol or chemical dependency treatment in the last year?
Your Children :
How many children do you have?
Have any of your children been diagnosed with (check if yes)
fetal alcohol syndrome
fetal alcohol effect
alcohol related birth defect
alcohol related behavior disorder
How many of your children have died? (Enter "0" for none)
Are any of your children living outside of your home (in foster care or adopted)?
Yes
No
Have any of them been in foster care?
Yes
No
Are any currently in foster care?
Yes
No
Are any adopted out of your home?
Yes
No
Have any of your children had a birth defect, development disability or mental retardation?
Yes
No
Do you sniff or inhale gas, glue or other substances to get high?
Yes
No
Do you use other drugs?
Yes
No
How many months pregnant are you today? (1- 9)
How many months pregnant were you when you first went for prenatal care?
How many of your friends drink with you?
Almost all
Some
None
Does your baby's father drink with you?
Yes
No
Does he drink more than you?
Yes
No
Have you been abused ?
Hit
Slapped
Hit in stomach
Verbally abused
Sexually abused
Other
When you were in school did you?
repeat a grade ?
have special classes ?
How much support do you have for a healthy life style?
Mark how much support you feel that you have
From partner:
1
2
3
4
5
6
7
8
9
10
From friends:
1
2
3
4
5
6
7
8
9
10
From family:
1
2
3
4
5
6
7
8
9
10
From my community:
1
2
3
4
5
6
7
8
9
10
by
Larry Burd, Ph.D.
North Dakota Fetal Alcohol Syndrome Center
PO Box 9037
Grand Forks, ND 58202-9037
Phone # 701-777-3683
Questions? Send them to
Laburd@medicine.nodak.edu
.