Prenatal Risk Assessment Questionaire

    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 to 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 Martial Status: (Check one)
    Married Widow Single Divorced
    Your Race/Ethnicity: (Check one)
    African American Native American Hispanic Asian Other
    Income: (Check one)
    TANF WIC Social Security Less than $18,000/yr 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 Pattern's
    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 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 your Partner:
    1 2 3 4 5 6 7 8 9 10
    From your Friends:
    1 2 3 4 5 6 7 8 9 10
    From your Family:
    1 2 3 4 5 6 7 8 9 10
    From your Community:
    1 2 3 4 5 6 7 8 9 10



    Questions? Send them to larry.burd@med.und.edu.