Prior-to-Pregnancy Maternal Risk Assessment

    Name or ID:                     

    Date of Birth:                    

    Medical Record Number: 

    Today's Date:                   

    Information you provide above will not be saved in a database.
    There will not be any record of your name, date of birth or medical record number.


    Please click the boxes that are applicable to you to complete the form below and find your prior to pregnancy risk score.
    Age over 25 years
    Marital Status: Unmarried, Divorced, Widowed , Living with Partner
    Income on TANF, WIC, Social Security, Income < $16,000 Per Year
    Did not graduate from high school
    Sniffs or inhales or uses other illegal drugs
    Is age first drunk less than 15 years
    Poor Diet
    Total times in treatment more than 3
    Smokes more than 1 pack per day
    Chemical dependency treatment in last 12 months

    Drinking > 5 days in last month
    Had > 5 drinks any day in last month
    More than 4 drinks any day in last week
    Average number of drinks when you drink > 4
    Drink on > 3 days in last week
    Drink 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?


    Results

    Prior-to-Pregnancy Risk Score:
    Risk Category:
    Recommendations:
    Alcohol Exposure: drinks
    Smoking Exposure: cigarettes
    Questions? Send them to larry.burd@med.und.edu.