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PRECONCEPTION HEALTH SCREENING & TUNE-UP FORM
Are you planning to become pregnant in the next six months? YES NO PLEASE CHECK THE BOX AND FILL IN (OR CIRCLE) OTHER INFORMATION THAT APPLIES TO YOU.
DIET & EXERCISE
MEDICAL/FAMILY HISTORY
Do you currently have or have ever had. Do you follow a special diet (vegetarian, diabetic, other)? Do you eat raw or under cooked food (meat, fish, other)? Do you have current/past problems with eating disorders? Do you take other vitamins daily?__Multivitamin __Vitamin A Other:_________________________________________ Do you take dietary supplements?__Black Cohosh __Pennyroyal Other:_____________________________________________ Do you exercise? Type:_______________________________ Frequency:_______________________________________ Which do you drink: ___coffee ___tea ___cola ___milk ___water Other________________________________________________ Depression or other mental health problems What do you consider a healthy weight for you? ______________________ Surgeries ___________________________________ Tune-Up Suggestions:
Other conditions_______________________________ • Work toward a healthy weight by exercising on a regular/routine basis.
Have you ever been vaccinated for: • All women of childbearing age should take a multivitamin that contains folic acid. Folic acid can reduce the chance of certain birth defects, especially when it’s taken before you get pregnant.
• If you are on a special diet, and plan on having a baby, talk to your health care provider about how to modify your diet during pregnancy.
LIFESTYLE
Tune-Up Suggestions:
• Be sure your immunizations are up to date before you consider becoming pregnant.
• Any medical conditions or problems should be discussed with your health care provider Do you smoke cigarettes or use other tobacco products? If yes, how many cigarettes per day?______________________ • Tell your health care provider if you are diabetic, or have your blood sugar checked regularly. High blood sugar can lead to birth defects, but it can be controlled.
If yes, what kind? __________________________________ MEDICATIONS/DRUGS
How often?__________________How much?_____________ Do you use non-prescribed (street) drugs? Are you taking prescribed drugs (Accutane, valproic acid, Circle any that apply (cocaine, heroin, ecstasy, meth/ice, marijuana, other) blood thinners)? If yes, list:_______________________ List:___________________________________________ Do you work or live near possible hazards (chemicals, X-ray or Are you taking non-prescribed (over-the-counter) drugs? other radiation, lead)? If yes, ____________________________ If yes, list:__________________________________ Do you use saunas, tanning beds, or hot tubs? What kind of work do you do?_________________________________ ____________________________________________________ Do you get injectable contraceptives or shots for birth control? Tune-Up Suggestions:
Do you use any herbal remedies or alternative medicine? • Visit your health care provider regularly to maintain your overall health.
If yes, list;__________________________________ • Have regular dental checkups, especially if you are pregnant or planning to become pregnant. Gum disease is associated with pre-term labor.
Tune-Up Suggestions:
• If you smoke, drink or use drugs, get the help you need to quit prior to pregnancy. Talk to your health care provider about: Smoking during pregnancy is associated with low birth weight infants and other poor • When to stop taking birth control if you’re planning to become pregnant.
birth outcomes. Alcohol can cause fetal alcohol syndrome, a devastating physical and • Any medications you’re taking whether over-the-counter or prescription. Certain medications can cause birth defects.
• Herbal remedies you may be taking. Some herbs may not be safe during pregnancy.
ESCAMBIA COUNTY HEALTHY START COALITION, INC.
PRECONCEPTION HEALTH SCREENING & TUNE-UP FORM
WOMEN’S HEALTH
GENETICS
DOES YOUR FAMILY OR YOUR PARTNER’S FAMILY HAVE A HISTORY OF: Do you have any problems with your menstrual cycle? PARTNER’S FAMILY
Have you had surgery on your uterus, cervix, ovaries or tubes? Have you ever had HPV, genital warts or chlamydia? How many times have you been pregnant?___________ If you have been pregnant before:
What was/were the outcome(s)?__________________________________ ______________________________________________________ Did you have difficulty getting pregnant the last time? Did your mother take the hormone DES during pregnancy? Have you ever been treated for a sexually transmitted infection (Genital herpes, gonorrhea, syphilis, HIV, AIDS, other)? Your ethnic background is:______________________ If yes, list treatments: ________________________________ ______________________________________ ______________________________________________ Your partner’s ethnic background is:________________ Tune-Up Suggestions:
______________________________________ • If you are trying to get pregnant, talk to your health care provider about the best timing Tune-Up Suggestions:
and/or frequency of intercourse for you to conceive.
• Your family’s medical history is important to know prior to • STIs (sexually transmitted infections) are frequently unrecognized (chlamydia, gonorrhea, herpes, genital warts, HIV).
• Genetic counseling can identify conditions which may affect your baby, • Testing is easy and available. Talk to your health care provider if you have any and gives you an opportunity to make important decisions.
HOME ENVIRONMENT
OTHER CONCERNS
Do you feel emotionally supported at home? Is there anything else you’d like your health care
Do you have help from relatives or friends if needed? provider to know? Write them below.
Do you feel you have serious money/financial worries?Are you in a stable relationship? Does anyone threaten or physically hurt you?Do you have pets (cats, rodents, exotic animals)? If yes, list:______________________________________ ____________________________________________ Do you have any contact with soil, cat litter or sandboxes? Are there any questions you‘d like to ask your
Baby preparation (planning for your baby):
health care provider? Write them below.
Do you have a crib for a baby to sleep in?Do you need any baby items? Can you afford to purchase a crib & diapers? Tune-Up Suggestions:
• A baby brings lots of new responsibilities. Here are some things you can be thinking about if you’re considering pregnancy: o Will the baby have clothes and other necessities? o Who will care for the baby if you return to work? Tune-Up Suggestions:
• You should feel free to talk to your health care provider about any fears or concerns you have! IMPORTANT: You may or may not be planning to get pregnant right away, but a check on your health and that of your
partner before a pregnancy begins is an important first step toward having a healthy pregnancy and health baby, when and if the time comes. Please use this completed form to guide your discussions with your health care provider.

Source: http://www.healthystart.info/docs/hschartcolor.pdf