High Risk Pregnancy Assessment

This short survey will only take a few minutes to complete and will help us monitor how you are doing. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.

Name

First Last

How would you rate your level of overall health and well-being?*

Have you been going to your prenatal wellness visits?*

Yes
Most of the time
Sometimes
No

Please let us know why you haven't been going to your prenatal wellness visits.

(Please select all that apply.)

Transportation issues
Child care issues
I forget about them
I cannot get off from work
I have problems making appointments
Other

You selected "other", why else are you not going to your prenatal wellness visits?*

Do you feel you need additional information on parenting skills?*

Yes
No

Do you feel you need additional information on managing home responsibilities?*

Yes
No

What home responsibilities would you like additional information on?*

(Please check all that apply.)

Paying for bills / daily living costs
Child care
Medical care
Housekeeping
Other

You selected "Other", what other responsibilities would you like additional information for?*

Please check the answer that comes closest to how you have felt IN THE PAST 2 WEEKS, not just how you feel today. Over the past 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things*

Not at all
Several days
More than half of the days
Nearly every day

Feeling down, depressed or hopeless*

Not at all
Several days
More than half of the days
Nearly every day

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Health Rating Score

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PHQ2 Score

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Call CC

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Call Provider or Hotline

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Take Edinburgh

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region

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county

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mobile

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status

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EscalationEmail

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MemberID