Pregnancy Tracking Sheet Page 2
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2Client Name: _________________________________ Birth Date: ________________Medicaid ID: ________________
Has client been tested for HIV/AIDs?
yes
no
unknown
client declines
Were results positive?
yes
no
unknown
client declines
Does client have STDs?
yes
no
unknown
client declines
What STDs?
chlamydia
hepatitis
syphilis
other
specify _______________________
cytomegalovirus
herpes
trichomonas
gonorrhea
HPV
unknown
Is client being treated for STDs?
yes
no
unknown
client declines
Is partner being treated for STDs?
yes
no
unknown
client declines
Is client a medical risk?
yes
no
unknown
Is client a nutritional risk?
yes
no
unknown
Is client a psychosocial risk?
yes
no
unknown
Comments:
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________________________________________________________________________________________________
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________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
__________________________________________________________________________________________________________
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________________________________________________________________________________________________
name
date
Tracking form completed by:
Data entered by:
Quality assurance inspection:
Department of Public Health Maternal Tracking Form (3/22/10)
Page 2 of 2
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