Prenatal Risk Assessment Questionaire

Enter name or ID
Enter Date of Birth
Enter the Medical Record Number
Enter Today's Date
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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
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
Does your baby's father drink with you?
Yes No
Does he drink more than you?
Yes No
Have you been abused?
Hit in stomach
Verbally abused
Sexually abused
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

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