BabyWiseSM Maternity Program Health Questionnaire

You can confirm your eligibility by sending a secure email, or calling 1 (888) 569-2229 during regular business hours. We will respond by the end of the next business day.

The information you provide is confidential and will not affect your health benefits. The best answer is an honest one so we can help support you during your pregnancy. Please complete this questionnaire to the best of your ability, and submit it to us by clicking the "Submit" button below.


Your Details
First Name
Last Name
Health Insurance ID#
Today's Date
What is your Date of Birth?
When is your baby due?
Who is providing your prenatal care?
  Name:
  Address:
  Phone:
When was your first prenatal visit?

You are expecting: One Baby Twins Triplets


Have you had problems with any of the following during your current or previous pregnancy?
Please check the appropriate box(es)
Current Pregnancy
Previous Pregnancy
Cerclage (cervix was stitched closed)
Gestational diabetes (diabetes only during your pregnancy)
Group B Strep infection
High blood pressure (toxemia, pre-eclampsia, or pregnancy induced hypertension)
Kidney or bladder infections
Oligohydramnios (too little fluid surrounding the baby)
Persistent vomiting
Placenta previa (placenta lies low in the uterus, partially or completely covering the cervix)
Polyhydramnios (too much fluid surrounding the baby)
Premature rupture of membranes
Preterm labor (labor starts before the 37th week of pregnancy)
Vaginal bleeding

List all of your previous pregnancies
Date
No. of weeks pregnancy lasted
Pregnancy ended by vaginal delivery, cesarean, miscarriage or abortion?
Baby's weight
Baby's sex
2/15/89
9
Miscarriage (Sample)
Unknown
6/15/93
42
Vaginal delivery (Sample)
6 lbs 2 oz
Boy

Boy
Girl

Add Pregnancy

List any medications you commonly use (including prescriptions, herbal/homeopathic treatments, over-the-counter medications such as Tylenol®, antihistamines, and vitamins including prenatal vitamins):
Is your blood type Rh Negative? Yes No
What is your height?
What is your Pre-pregnancy weight?
How many servings of each food group do you eat during an average day?
  Breads/Cereals Fats/Oils
  Meat/Protein Fluids (8 oz cups)
  Vegetables Milk/Dairy
  Fruits    

Do you exercise on a regular basis?
  No Yes If yes, how Often? Type:
Do you, the father of your baby, or any of your children have a history of any genetic disease (including, but not limited to, Down Syndrome, spinal cord defects, hemophilia, muscular dystrophy, etc.)?
  Yes List the condition
  Who has this condition? You Baby's father Your child
  No      
  I don't know      
Did your mother take DES (Diethylstillbestrol; was used until 1971 to prevent miscarriages) while she was pregnant with you?
  Yes No I don't know

Do you have a history of any of the following when you're not pregnant (check all that apply):
Allergies
Anemia (needing treatment)
Asthma
Depression/Anxiety
Diabetes Type I Type II
Eating Disorder
Heart Disease (treatment)
Hepatitis A B C
Herpes
High blood pressure (what is normal for you?)
HIV positive
Hospitalized for mental health condition
Infertility
Lupus
Multiple Sclerosis
Phlebitis (blood clots in your legs)
Seizure disorder (treatment)
Sexually transmitted disease
Surgery (list)
Uterine fibroids and/or abnormalities
Other
None of the above

Have you had chicken pox or the vaccine for chicken pox? Yes No
Do you smoke? Yes Less than 1 pack/day More than 1 pack/day
  No        
Someone else in my household smokes
Since you've known you were pregnant, how many alcoholic beverages do you drink each week, if any?
  None 1 to 2 drinks   More than 2 drinks
Since you've known you were pregnant, have you used any recreational drugs (e.g., cocaine, marijuana, etc?)
  No Yes Please List
Abuse during pregnancy carries a higher risk of prematurity and is more common than most people realize. Abuse is defined as being hit, slapped, kicked, forced to have sex, or otherwise physically hurt by anyone. During the past year have you suffered any type of abuse?
  No Yes
Rate your overall stress level on a scale of 1-10 (1 Low - 10 High)
Which of the following best describes your current support system? (check all that apply)
    Spouse/Partner Family Friends Other
    Club/Organization Church None    
What is your marital status?
What is your ethnic origin?
What is the highest level of education you have completed?
Are you currently employed?
  Yes No How many hours per week?
What is the best way for us to reach you for follow-up?
    By phone (daytime)   By Email