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Maternal Health Assessment

Date*field type date
Date will be captured on form submission
Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Age*field type number

Maternal Health History Questions

section

Where do you go for prenatal/postpartum care? Doctor/clinic name?*field type single line
Input blocked. Maximum character limit of 45 characters reached.
Check all pregnancy and delivery related conditions you have or had in the past*field type checkbox
Check all pregnancy and delivery related conditions you have or had in the pastGestational DiabetesHigh Blood PressurePregnancy LossEarly Baby (Less than 39 weeks)Small Baby (5 pounds 8 ounces, or less)Large Baby (9 pounds or more)Baby born with health problemOtherN/A
Other pregnancy and delivery related conditions*field type single line
Input blocked. Maximum character limit of 80 characters reached.
Do you have any medical conditions, illness, food allergies, or a recent surgery or injury?*field type radio button
Do you have any medical conditions, illness, food allergies, or a recent surgery or injury?YesN/A
If Yes, Please describe any medical conditions, illness, food allergies, or a recent surgery or injury?*field type single line
Input blocked. Maximum character limit of 100 characters reached.
Do you take any medications or herbs?*field type radio button
Do you take any medications or herbs?YesN/A
If Yes, What medicaions or herbs?*field type single line
Input blocked. Maximum character limit of 52 characters reached.
Do you or your dentist have any dental concerns?*field type radio button
Do you or your dentist have any dental concerns?YesNoI don't have a dentist
If Yes, What concerns?*field type single line
Input blocked. Maximum character limit of 20 characters reached.
Has anyone in your family been tested for lead?*field type radio button
Has anyone in your family been tested for lead?YesNoI don't know
If Yes, What levels?*field type single line
Input blocked. Maximum character limit of 18 characters reached.
Have you been/are you being treated for depression or other mental health concerns?*field type radio button
Have you been/are you being treated for depression or other mental health concerns?YesNo
Over the past two weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things:*field type radio button
Little interest or pleasure in doing things:Not at allSeveral DaysMore than half the daysNearly every day
Feeling down, depressed, or hopeless:*field type radio button
Feeling down, depressed, or hopeless:Not at allSeveral DaysMore than half the daysNearly every day
Do you live in a temporary place (shelter, hotel, etc.)?*field type radio button
Do you live in a temporary place (shelter, hotel, etc.)?YesNo
Have you been physically, verbally, sexually abused, or neglected?*field type radio button
Have you been physically, verbally, sexually abused, or neglected?YesNo
Are there times when anyone makes you feel unsafe?*field type radio button
Are there times when anyone makes you feel unsafe?YesNo
Do you have a safe place to go?*field type radio button
Do you have a safe place to go?YesNo
Do you worry about running out of food?*field type radio button
Do you worry about running out of food?YesNo
Do you use local food banks/pantries?*field type radio button
Do you use local food banks/pantries?YesNo
What questions or concerns do you have about your health, eating habits, and breastfeeding?field type single line
Input blocked. Maximum character limit of 150 characters reached.

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