Prenatal Intake Form
 “Find a Pregnant Momma” Assignment
N305: Nursing and the Childbearing Family
Lakeview College of Nursing 

Name: First and Last Initials Only (maintain confidentiality) ________________

Birth Partner, If Any _________________________________  Relationship _____________________

Pregnancy Information

EDC (Due Date) _____________	Physician(s) Delivering __________________________________

Pregnancy Number (1, 2, 3, etc.) ____	Number of Children Living ____

Number of Previous Pregnancies _____

Complications During This Pregnancy __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Complications During Previous Pregnancies
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Breast or Bottle Feeding? _________________________________________________________________

Attended Childbirth Classes? _________   If Yes, Where? _______________________________________

Client is at risk of poor pregnancy outcome because of the following: (check all that apply)

_____	History of previous low birth weight infant
_____	Seventeen years or younger at time of delivery
_____	Recent or current alcohol use
_____	Recent or current illicit drug use
_____	Recent or current smoker
_____	Pre-pregnancy underweight (BMI < 19.8)

-OR-

Client is at risk of poor pregnancy outcome because of at least 3 of the following: (check all that apply)

_____ Recent delivery
_____ Inadequate weight gain
_____ Education level less than appropriate for age
_____ History of or current domestic violence
_____ History of abuse in childhood
_____ High life stress (having any 4 factors as defined below)
_____ History of or current psychiatric diagnosis, including depression
_____ Not married

_____ Cognitive or developmental disability
_____ Age 18 at time of delivery
_____ Age 35 or greater at time of delivery

RISK FACTOR DEFINITIONS

Poor pregnancy outcome definitions:

1.	History of previous low birth weight infant – Birth weight was 5 lbs 8 ozs (2500 gm) or less

2.	Seventeen years or younger at time of delivery – Determine using age as of estimated date of conception (EDC)

3.	Recent or current alcohol use – Any current use of alcohol; any use after conception including prior to knowledge of pregnancy; any use within the 3 months prior to conception

4.	Recent or current illicit drug use – Any current use of marijuana, cocaine, heroin, amphetamines or other illicit drugs, or misuse of prescription drugs; any use after conception, including prior to pregnancy confirmation; any use within the 3 months prior to conception

5.	Recent or current smoker – Any current use of tobacco; any tobacco use after conception, including prior to pregnancy confirmation; any use within the 3 months prior to conception

6.	Pre-pregnancy underweight (BMI < 19.8)  - Use the BMI chart, wheel or other calculation to determine client’s BMI according to height and known or estimated weight prior to conception

7.	Recent delivery – Less than 12 months between date of last delivery and date of conception

8.	Inadequate weight gain during pregnancy – Weight loss below the appropriate line, weight loss below pre-pregnancy weight in the first trimester, or weight loss of two pounds or more in the second or third trimester; weight gain of less than two pounds per month during the second or third trimester; or any weight gain which falls below the expected rate of gain

9.	Education level – Has not graduated from high school, does not have a GED, or less than appropriate for age (i.e. 15 year old in 7th grade)

10.	History of or current domestic violence – Includes verbal, emotional, physical or sexual abuse

11.	History of abuse in childhood – Includes verbal, emotional, physical or sexual abuse

12.	High life stress (at least 4 factors needed) – Within the last 12 months…. (indicate all that apply)

•	The client has had a death of someone very close to her
	
•	She or her husband or partner went to jail
•	A close family member was very sick and had been admitted to the hospital

•	Someone very close to her has had drug or alcohol problems

•	She was separated or divorced from her husband or partner

•	She has moved to a new address

•	She was homeless

•	Her husband or partner lost his job

•	She lost her job even though she would have wanted to go on working

•	She argued with her husband or partner more than usual

•	Her husband or partner said he didn’t want her to be pregnant

•	She had a lot of bills she couldn’t pay

•	She was in a physical fight

13.	History of or current psychiatric diagnosis, including depression – Documentation of psychiatric hospitalization; outpatient treatment or psychotropic medication; expresses suicidal ideation; exhibits bizarre/psychotic speech or behavior; exhibits signs and symptoms of depression

14.	Not married – Includes women who are living with a partner but not married; common-law marriages and women who are pursuing divorce, but are not yet divorced, are considered married

15.	Cognitive or developmental disability – Includes women who are developmentally disabled, have traumatic head injuries, or other cognitive impairments that reduces their ability to understand and follow provider education or instructions

16.	Age 18 at time of delivery – Determine using age of EDC

17.	Age 35 or over at time of delivery – Determine using age as of EDC