Notification of Pregnancy

Member ID#

*Date of Birth

*Last Name

*First Name

*Mailing Address

City

State   Zip

*Phone

Email Address

*Due Date

First Prenatal Visit Date

*OB- GYN Clinic/Doctor

Member Risk Factors

Member History

High Risk Pregnancy —Please choose an option—NoYes

Preterm labor —Please choose an option—NoYes

Tobacco use —Please choose an option—NoYes

Twins/Multiples —Please choose an option—NoYes

Substance use disorder —Please choose an option—NoYes

Miscarriage —Please choose an option—NoYes

Alcohol abuse —Please choose an option—NoYes

Stillbirth —Please choose an option—NoYes

Diabetes/Gestational diabetes —Please choose an option—NoYes

Infant death —Please choose an option—NoYes

Other

Current tobacco use —Please choose an option—NoYes    If yes, would you like a quit kit —Please choose an option—NoYes

If maternal age <18, may we contact member’s parent? —Please choose an option—NoYes

Refer member to UPHP Case Management? —Please choose an option—NoYes