The earliest possible completion of this form allows us to best use our resources and services to help you or your patient achieve a healthy pregnancy outcome. If you have any questions completing this form, please call 1-855-242-0802, TTY/TDD 711.

This form was completed by: Provider Member Member Rep

Member ID

Last Name First Name

Date Of Birth

Mailing Address

City State Zip

Home Phone Cell Phone

Email Address

Due Date Unknown

Preferred Language

Date of first Prenatal Visit Pre-pregnancy Weight

Race/Ethnicity (fill in all that apply)

White Black/African American Hispanic/Latina

American Indian/Native American Hawaiian/Pacific Islander Asian

Other Please Specifiy

Number of Full Term Deliveries Number of Stillbirths

Number of Pre-Term Deliveries Number of Miscarriages/Abortions

If there are no known risk factors, please check this box

Are any of the following risk factors present?

History (fill in all that apply):

Current Pregnancy (fill in all that apply):

Previous Pre-Term (<37 weeks) delivery? Twins? Triplets? Discordant?

If yes, was the delivery spontaneous?

Is the member a candidate for progesterone injections? Pre-Term labor this pregnancy?

Recent delivery (within the past 12 months)? Shortened Cervix <23 weeks this pregnancy? Length

Previous C-Section? Cervical Cerclage placement?

Diabetes (prior to pregnancy)? Current severe hyperemesis?

Sickle Cell? Current mental health concerns? List

Asthma?

High Blood Pressure (prior to pregnancy)? Current STD? List

HIV Positive? Current tobacco use? Amount

Seizure Disorder? Current alcohol use? Amount

Seizure within the last 6 months? Current street drug use?

Previous alcohol or drug abuse?

OB Provider Name:

TIN/ID number: Phone Number:

Mailing Address:

City: State: Zip Code: