Pregnancy Tracking Sheet
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1
2Client ID: ___________________
Admission ID: ________________
Medicaid ID: ________________
Pregnancy Tracking
This form is to be filled out at each contact.
Client's name
_____________________________________________ Maiden name ________________
(first, middle, last)
Birth date ____/____/____
Social Security # ______________________________
Street address ___________________________________________ Apt# ________________ County ______________
City _________________________________________ State ____________________ Zip code ___________________
Home phone ____________________ Message phone ____________________ Work phone ____________________
Emergency contact __________________________________________ Phone ________________________________
st
nd
rd
Contact date: _____/_____/_____
Stage of pregnancy:
1
trimester
2
trimester
3
trimester
WIC certified?
yes
no
Taking prenatal vitamins, including folic acid?
yes
no
unknown
Attending childbirth education classes?
yes
no
unknown
Attending parenting education classes?
yes
no
unknown
Is client receiving prenatal care?
yes
no
unknown
How many prenatal visits scheduled? ___________ How many kept? ___________
Allergies?
yes
no
unknown
Specify:___________________________________________________
Is client taking regular medications?
yes
no
unknown
What medications?
antibiotics
pain meds
antidepressants
other
anti seizure meds
specify ________________________
Smoke cigarettes?
yes
no
unknown
How many cigarettes per day?
<1
10-20
more than 2 packs
1-5
1 pack
unknown
5-10
1-2 packs
Drink alcohol?
yes
no
unknown
How often?
never
less than 1 drink/week
2-6 drinks/week
1 drink/day
more than 1 drink/day
Use illicit drugs?
yes
no
unknown
client declines
What drugs?
cocaine
heroin
unknown
crank
marijuana
other
crack
methamphetamine
specify _________________________________________
Department of Public Health Maternal Tracking Form (4/18/08)
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