Client’s Demographics

Name: ________________________________________________ Date: _____________

(Last name) (First name) (Middle initial)

Age: ______ Gender: Male Female Date of Birth: _________________

Place of Birth: _________________________________________________________________

Husband/Partner’s Name: ____________________________________ Age:_____________

(Last name) (First name) (Middle initial

Current Address: _______________________________________________________________

Country: __________________________________ Postal Code: ___________________

Nationality: _____________________ Languages/Dialects: _________________________

Religion: _____________ Marital Status: Single Married Divorced

Widowed

Ordinal Position: _______________________ Number of Children: ____________

Educational Attainment: ______________________ Occupation: ___________________

Work Address: _________________________________________________________________

Client’s History:
_________________________________________________________________

Client’s Physician: ________________________________________

History of Substance Abuse

a) Smoke  Yes No

Before pregnancy: __________packs/day
During Pregnancy: __________packs/day

b) Drink Alcohol  Yes Specify: ________________ No

Before pregnancy: __________ glasses/bottles a day
During Pregnancy: __________ glasses/bottles a day

c) Illegal drugs  Yes Specify:________________ No

Before pregnancy: __________
During Pregnancy: __________

Does anyone smoke inside your house?  Yes No

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 Prenatal care

How many months are you pregnant? ______________

How many prenatal visits did you have? ______________

Are you experiencing any of the following danger signs?

 Severe headache Vaginal bleeding

 Convulsion Fever
 Severe abdominal pain Paleness

Are you aware of the essential care for your baby within the first 24 hours of his/her life?

Yes  No

How is your pregnancy going? How are you feeling?

_____________________________________________________________________________

Do you intend to practice family planning after giving birth? Yes  No

How much did you weigh before this pregnancy? ________lbs

Current weight: ______ lbs Date: _________ Height: _______

Instruction of the Schedule of next

Date of Name and
Service(s) Provider (Including visit to provider
Consultation Address of
Provided Referral to higher for check-up
(mm/dd/yy) Service Provider
level and schedule ) (mm/dd/yy)

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Last Menstrual Period: ________________ Estimated Date of Confinement: ______________

Age of Gestation: ___________________ Fundic Height: _______________________

Baby’s Physician: _______________________

Nutritional and Dental Status

Nutritional Status

1. Do you ever run out of food before the end of the month or cut down on the amount you eat
to feed others?  Yes No
(If Yes) Tell me more. ____________________________________________________
2. Do you have any special dietary requirements (eg. vegetarian, vegan, allergies)?
 Yes No
If yes, please specify: _________________________________________________________
3. Weight, height and BMI
a. Weight ________kg
b. Height _________m
c. (Health care professional to complete): Divide weight in kg by height in metres² (m²),
then divide the answer by your height again to get your BMI. BMI is ______kg/m2
4. Quality of diet
Do you eat meat or chicken 2-3 times per week?  Yes No
Do you regularly eat more than 2 – 3 portions of fruit or vegetables per day?
 Yes No
Do you eat fish at least 1-2 times per week?  Yes No

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 Do you consume dairy products (such as milk, cheese, and yogurt) every day?
 Yes No
Do you eat whole grain carbohydrate foods (brown bread, brown pasta, brown rice or
other) at least once a day?  Yes No
Do you consume packaged snacks, cakes, pastries or sugar-sweetened drinks less than 5
times a week?  Yes No

5. Other information

If you are pregnant, did/do you take folate/folic acid supplements in pre-pregnancy and in
early pregnancy (first 12weeks)?  Yes No
Do you get regular exposure to the sun (face, arms and hands for at least 10-15 mins per
day)?  Yes No
Has the doctor/nurse tested your haemoglobin (level of iron in the blood)?
 Yes No
(Health care professional to complete) If yes, is it more than 110 g/l?
 Yes No

Dental Status
1. When was the last time you saw a dentist?________________
2. Do you have any problems with your teeth or gums that affect how you eat?  Yes
No

(If Yes) What are your problems? ________________________________________

Abuse/Violence

1. Have you ever been emotionally abused by your partner or someone important to you?
 Yes No

2. Since you’ve been pregnant, have you been slapped, kicked or otherwise physically hurt
by someone?  Yes No
If Yes, by whom? (check all the apply)  Husband  Ex Husband Boyfriend
Stranger Other(specify):_____ Multiple
Total no. of times: _______
3. Has anyone forced you to have sexual activities?
 Yes No
If yes, by whom? (check all the apply)  Husband  Ex Husband Boyfriend
Stranger Other(specify):_____ Multiple
Total no. of times: _______
4. Are you afraid of your partner or anyone cited above?
 Yes No  Multiple (please specify):___

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 Obstetric History

Place of
Duration
Delivery Type of Complications Mother Birth Present
Year of Sex
or Delivery and/or Infant Weight Health
Pregnancy
Abortion

G _____, T _____, P _____, A _____, L ______, M _____

Did you have gestational diabetes, high blood pressure, depression or postpartum depression
with your last pregnancy?  Yes No

(If yes) Tell me more.____________________________________________________

Did your baby (babies) have any health or medical problems at birth?  Yes No

( If yes) What were they?___________________________________________________

Cite any obstetrical/gynecological surgeries you have undergone:_____________________

Cite other non-obstetrical/non-gynecological surgeries:______________________________

Medical Problems

 Arthritis Kidney Disease Asthma

 Diabetes Gallstone Emphysema
 Diet Controlled Liver Disease Bronchitis
 Pill Controlled (including Hepatitis)  HIV+
 Insulin Controlled Epilepsy Eating Disorder
 High Blood Pressure Blood Transfusions  Other: _____________________
 Heart Disease Thyroid Disease

Do you have any health problems or medical conditions not related to pregnancy? (Yes or No)__

(If Yes) Tell me more. ____________________________________________________

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Laboratory Results

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https://www.slideshare.net/naehomelessness/13-abuse-assessment-screen

Abuse or violence

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