Prior-to-Pregnancy Maternal Risk Assessment

Name or ID:                     

Date of Birth:                    

Medical Record Number: 

Today's Date:                   

Information you provide above will not be saved in a database.
There will not be any record of your name, date of birth or medical record number.

Please click the boxes that are applicable to you to complete the form below and find your prior to pregnancy risk score.
Age over 25 years
Marital Status: Unmarried, Divorced, Widowed , Living with Partner
Income on TANF, WIC, Social Security, Income < $16,000 Per Year
Did not graduate from high school
Sniffs or inhales or uses other illegal drugs
Is age first drunk less than 15 years
Poor Diet
Total times in treatment more than 3
Smokes more than 1 pack per day
Chemical dependency treatment in last 12 months

Drinking > 5 days in last month
Had > 5 drinks any day in last month
More than 4 drinks any day in last week
Average number of drinks when you drink > 4
Drink on > 3 days in last week
Drink today

Previous child died
Children out of home (foster care or adopted)
Previous child with Birth Defect or Developmental Disability
Previous child with FAE
Previous child with FAS

On average how many days per week do you drink?
On an average drinking day how many drinks do you have?
On average how many days per week do you smoke?
On an average day how many cigarettes do you smoke?


Prior-to-Pregnancy Risk Score:
Risk Category:
Alcohol Exposure: drinks
Smoking Exposure: cigarettes

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