Prenatal Risk Assessment Form Please update the form and resend with any new information or risks associated with this pregnancy. The following information is required by EOHHS. OB-GYN Name 1st Date of Service MM slash DD slash YYYY OB Site FaxOB Site Email Address(Required) Member ID Name DOB MM slash DD slash YYYY Member's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneLMP (if known) EDD (if known) Gravida Para AB Living Consent Signatures confirm the Provider has discussed the referral with the patient and the patient has consented to telephonic contact by a case manager from our Behavioral Health partner. Referrals can also be made at any time with or by the patient by calling the Behavioral Health partner directly at (401) 459-6681. Consent Signatures for a Behavioral Health referral is required. REFERRAL FOR BEHAVIORAL HEALTH CASE MANAGEMENTREFERRAL FOR BEHAVIORAL HEALTH CASE MANAGEMENTNoYesReferral Reason Consent Date MM slash DD slash YYYY Patient SignatureProvider SignatureDate Prenatal Risk Assessment Completed by Provider MM slash DD slash YYYY BEHAVIORAL HEALTH PRA - PLEASE CHECK ALL RISKS THAT APPLY* Anxiety Sexual Abuse Anorexia Bipolar Disorder Substance Abuse History of PTSD Depression Suicidal Attempts Other BH Issues History of Postpartum Depression Psychosis No Risk Other BH Issues *Risks checked off or written on this form do not ensure enrollment into the Bright Start Case Management Program. Neighborhood assumes the provider is managing all risks identified on this formMEDICAL PRA - PLEASE CHECK ALL RISKS THAT APPLY History of Pre-term delivery (less than 36 weeks GA) and receiving weekly injections (17P) Adherence to Injection - Yes Adherence to Injection - No Current Diabetes Mellitus Current Diabetes Mellitus - Active at High Risk Clinic Pre-existing or chronic HTN/ on medication Pre-existing or chronic HTN/ NO medication Short-term pregnancy interval (< 12 months) Smoking No risk 2ND/3RD TRIMESTER RISKS Health care non-adherence - Not following treatment plan Health care non-adherence - Not keeping appointments Current preeclampsia/eclampsia Gestational diabetes Gestational diabetes - Active in High Risk Clinic NEIGHBORHOOD REFERRAL FOR MEDICAL CASE MANAGEMENTNEIGHBORHOOD REFERRAL FOR MEDICAL CASE MANAGEMENTNoYesReferral reason Have you discussed the referral with your patient?Have you discussed the referral with your patient?NoYesEmail NameThis field is for validation purposes and should be left unchanged.