PRIOR-TO-PREGNANCY RISK SCORE

---

Please enter name or ID
Please enter Date of Birth
Please enter the Medical Record Number
Please enter today's date
The information you provide will not be saved in a database. There will not be a record of your name, date of birth or medical record number.

---

Please complete the form below to find your prior to pregnancy risk score
Click the boxes that are applicable to you

Age over 25 years
Marital Status: Unmarried, Divorced, Widowed, Living with Partner
Income: TANF, WIC, Social Security, Income < $16,000 Per Year
Did not graduate from high school
Sniffs, inhales or uses other illegal drugs
Age first drunk less than 15 years
Poor Diet
Total times in drug or alcohol treatment more than 3
Smokes more than 1 pack per day
Chemical dependency treatment in last 12 months
Drank alcohol more than 5 days in the last month
Had more than 5 drinks during any day last month
More than 4 drinks during any day in the last week
Average number of drinks when you drink is greater than 4
Drank greater than 3 days in the last week
Drank today
Previous child died
Children out of home (foster care or adopted)
Previous child with Birth Defect or Developmental Disability
Previous child with FAE
Previous child with FAS

---

On average how many days per week do you drink?
On an average drinking day how many drinks do you have?
On average how many days per week do you smoke?
On an average day how many cigarettes do you smoke?

---

Prior-to-Pregnancy Risk Score
Risk Category
Recommendations
Alcohol Exposure	drinks
Smoking Exposure	cigarettes

---

     Questions? Send them to Laburd@medicine.nodak.edu.