Fillable Member Notication of Pregnancy

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Member Notication of Pregnancy

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The Member Notication of Pregnancy form is 2 pages long and contains:

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  • 7 check-boxes
  • 122 other fields

Country of origin: OTHERS
File type: PDF

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Member Notification of Pregnancy
T
his form is confidential. If you have any problems or questions, please call
Absolute Total Care at 1-866-433-6041
(TTY: 711). This form is also available
online at absolutetotalcare.com.
*Required Field
*Are You Pregnant?
Yes No * If you are pregnant, please continue to answer all the questions.
Return the form in the envelope provided. When your answers are received, a gift will be mailed to you!
We may call you if we find that you are at risk for problems with your pregnancy.
*Medicaid ID #: Today’s Date MMDDYYYY:
Your First Name:
Your Last Name:
*Your Birth Date MMDDYYYY:
Mailing Address:
City: State: Zip Code:
Home Phone: Cell Phone:
Would you like to receive text messages about pregnancy and newborn care? Yes No
If you do not have an unlimited texting plan, message and data rates may apply. Text STOP to unsubscribe.
Please note, texting is not secure and may be seen by others.
Email Address:
*Your OB Provider’s Name:
*Your Due Date MMDDYYYY:
Primary insurance (for mom or baby) other than Medicaid? Yes No
Race/Ethnicity (select all that apply): White Black/African American Hispanic/Latina
American Indian/Native American Asian Hawaiian/Pacific Islander
Other If other ethnicity, please specify:
Preferred Language (if other than English):
Planning to breastfeed? Yes No If no, what is the reason?
Pediatrician chosen? Yes No Pediatrician Name:
Number of Full Term Deliveries: Number of Miscarriages:
Number of Preterm Deliveries: Number of Stillbirths:
Height (Feet, Inches):
Pre-Pregnancy Weight:
*Do you have any of the following? Yes No If yes, mark all that apply.
Your Medical History
Previous preterm delivery (<37 weeks or a delivery more than three weeks early)? Yes No
Recent delivery within past 12 months? Yes No Was delivery within past 6 months? Yes No
Previous C-Section? Yes No Diabetes (Prior to Pregnancy)? Yes No
© 2020 Start Smart for Your Baby. All rights reserved.
ATC-01292020-M-2
Rev. 12 19 2019
SC-MNOP-2050
*Medicaid ID #:
Name: Last, First:
Sickle Cell? Yes No
Asthma? Yes No If yes, are asthma symptoms worse during pregnancy? Yes No
High blood pressure (prior to pregnancy)? Yes No Previous neonatal death or stillbirth? Yes No
HIV Positive? Yes No HIV Negative? Yes No Testing refused? Yes No AIDS? Yes No
Thyroid Problems? Yes No If yes, is this a new thyroid problem? Yes No
Seizure Disorder?
Yes No Seizure within the last 6 months? Yes No
Previous alcohol or drug abuse? Yes No
Current Pregnancy History
Preterm labor this pregnancy? Yes No Current gestational diabetes? Yes No
Current twins? Yes No Current triplets? Yes No
Currently having severe morning sickness? Yes No
Current mental health concerns? Yes
No
List:
Current STD? Yes No List:
Current tobacco use? Yes
No
Amount:
If yes, are you interested in quitting?
Yes
No
Current alcohol use? Yes No Amount:
Current street drug use? Yes No
Taking any prescription drugs (other than prenatal vitamins)? Yes No List:
Any hospital stays this pregnancy?
Yes No
If yes, please list hospitalizations during this pregnancy.
Social Issues
Do you have enough food? Yes No Are you enrolled in WIC? Yes
No
Do you have problems getting to your doctor visits? Yes No Do you have reliable phone access? Yes No
Are you homeless or living in a shelter? Yes No
Are you currently experiencing domestic violence or feel unsafe in your home? Yes No
Please list any other social needs you may have:
Please list anything else you would like to tell us about your health:
© 2020 Start Smart for Your Baby. All rights reserved.
Rev. 12 19 2019
SC-MNOP-2050-2
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Member Notication of Pregnancy

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Completed 3 May 2021

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