Maternal and Child Assessment tool

Clients Name: __________________________ Emergency contact person/s

Nickname: _____________________________ Name: _______________ Age: ___
Client’s DOB: ___/___/___ Client’s Age: ____ Relationship: __________________
Client’s ins. Type & no.: __________________ Phone: ______________________
Client’s SS no.: _________________________ Address: _____________________
Client’s race: ___ White ___ Black ____________________________
___ Hispanic ___ others Doctor (must use PCP if applicable)
EDC: _________ Weeks Gestation: _________
Primary language: _______________________ Name: _______________________
___ Home ___ Shelter ___ Homeless Hospital: _____________________
___ staying with relatives Phone: _______________________
Current residence address: Address: _____________________
______________________________________ Consulting Doctors on Care
______________________________________ Phone: _______________________
Phone: ________________________________ 1.) __________________________
Best time to contact: _____________________ 2.) __________________________
Diagnoses 3.) __________________________
1.) ___________________________________ Other Consultants:
2.) ___________________________________ 1.) SW: ______________________
3.) ___________________________________ 2.) Other: _____________________
Exacerbating Potentials:
____________________________________________________________________
1.) Planned hospital for delivery: _________________________________________
2.) History of Prenatal care this pregnancy: _________________________________
3.) Planned Delivery:
___ Vaginal ___ C-section
I. Prior OB History: G: ___ P: ___
PIH: __________ GDM: __________ IDDM: __________ Eclampsia: __________
# Of Children living w/ her, and their ages: _____________________________________
_______________________________________________________________________
_
Any children in foster care, or living elsewhere: _________________________________
II. Current state of health:
1. Physical
2. Mental
3. Emotional
4. Social
5. Hospitalizations/ Surgeries
6. Diet/ Nutrition/ Weight prior to pregnancy; weight gain so far
7. Activity
8. Physical Limitations
9. Support systems
10. Limitations
11. Medications- Time, Frequency, Amt, Purpose, Side Effects
12. Teaching needed
____ Transportation ____ Self-Treatment
____ Changes during pregnancy
____ Nutrition ____ Home Safety ____ Community resources
____ Utilities ____ Cooking

____ Phone ____ Water

____ Housing ____ respite
____ ref. ____ others
____ Growth/ Development
____ Parenting Education
____ Budgeting of Financial Resources
____ Parenting Skills ____ Parenting Education
____ Gestational Diabetes ____ Pre-mature labor
____ Rupture of membranes ____ Signs/ Symptoms of Labor
13. Referrals already made: ___________________________________________
14. Referrals needed: ________________________________________________
____ WIC ____ Wheels