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This form is to be completed for Blue Choice Option, HMOBlue Option, Blue Option Plus, Premier Option,Premier Option Plus, Premier Child Health Plus and Child Health Plus members only.
Date Completed
Date of First Prenatal Visit
Patient Name
Date Of Birth
Subscriber ID
Street Address 1
Street Address 2
City
State
Zip Code
Phone Number
Estimated date of confinement
Diagnosis
Type of pregnancy
Gravida
Para
Registered for Prenatal Care
Weeks by LMP/Ultrasound
Race
Primary Prenatal Care Provider
NPI
Provider Phone Number
Hospital (for delivery)
Trimester
Automatic referral if four or more risk factors from this category or for active domestic violence
Social Risk Factors
Is Physical/Sexual Abuse a Current Problem?
For II, III and IV, automatic referral if five or more risk factors identified from all three categories combined
Maternal Medical History
Automatic referral if desires counseling, current substance abuse or mentally/physically challenged
Psycho-Neurological History
Previous Counseling Evaluation or Treatment,
For How Long?
Substance/Alcohol Abuse Hx.
List Substances
Mentally/Physically Challenge
Describe Mental/Physical Challenge
Automatic referral for any history or current PTL or <12 months between births
Maternal Obstetrical History
Previous Uterine Surgery
Describe
Tocolytics Used
Used at How Many Weeks Gestation
Eating Disorder
List Disorder(s)
Automatic Referral for any history of preterm birth or stillbirth
Previous Infant Findings
Other previous infant findings
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