B4 3Ps_Prenatal Form_revised

Healthy Start Prenatal Screening Tool | August 2016

OMB #: 0915-0338

Expiration Date: XX/XX/XXXX

Name: _________________________________________________________

Completed by: ________________________Date of Administration: ___________________

This tool should be completed for women in prenatal period. The prenatal period refers to the time period from diagnosis of pregnancy to birth.

Some key aims during this phase:

• Improve health risk screening for all pregnant women

• Provide evidence-based tobacco cessation counseling

• Refer and treat women with substance abuse and mental health disorders

• Increase access to and quality of prenatal care

• Support comprehensive home visiting programs.

The questions and answer choices were selected based on the available evidence about factors that may impact a woman’s health or pregnancy outcomes. The information provided by the participant through this screening tool will help Healthy Start identify each participant’s unique needs and ensure that she is connected to the appropriate support services.

Please read the questions to the participant. Only read the responses to the participant if the instructions for any question tell you to do so.

Please read the following statement to the participant: Thank you for taking time to complete this interview. Any information you provide will be kept confidential to the extent allowed by law. You do not have to answer any question you do not want to, and you can end the interview at any time.

Readiness for Motherhood/Prenatal Care

Let’s start off by asking some questions about your pregnancy.

1. How many weeks or months pregnant are you?

STAFF: Please enter number of weeks OR number of months.

______ Weeks OR ______Months

• Don’t know

• Declined to answer

2. What is your baby’s due date?

Due Date: __/__/____

• Don’t know

• Declined to answer

3. When you got pregnant with this baby, were you trying to get pregnant?

Select one only.

• Yes

• No

• Don’t know

• Declined to answer

4. How do you feel about being pregnant?

STAFF: Please read responses to participant.

Select one only.

• Very unhappy to be pregnant

• Unhappy to be pregnant

• Not Sure

• Happy to be pregnant

• Very happy to be pregnant

DO NOT READ OUT LOUD:

• Don’t know

• Declined to answer

5. What method do you plan to use to feed your new baby in the first few weeks?

Select one only.

• Breastfeed only (baby will not be given formula)

• Formula feed only

• Both breast and formula feed

• Don't know yet

• Declined to answer

6. Where are you planning to deliver your baby? At a hospital, birthing center, home, or some other place?

Select one only.

• Hospital

• Birthing center

• Home

• Other place: _________________

• Declined to answer

7. How many weeks or months pregnant were you when you had your first visit for prenatal care? Do not count a visit that was only for a pregnancy test or only for WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children).

STAFF: Please enter number of weeks OR number of months.

_____ Weeks OR ______ Months

• Don’t know

• Declined to answer

• I didn’t go for prenatal care (Go to question 8)

8. Have you had any difficulty getting the prenatal care you want or need?

Select one only.

• Yes (Go to question 8.1)

• No (Go to question 9)

• Declined to answer (Go to question 9)

8.1 Please tell me the reasons it has been difficult to get prenatal care?

Select all that apply.

• OB provider won’t schedule an appointment until the end of the first trimester

• OB provider refused to schedule an appointment because my pregnancy is advanced, # of weeks_______________

• I couldn’t get an appointment when I wanted one

• I couldn’t find a doctor or clinic that accepted Medicaid

• It is hard to communicate with the doctor or clinic staff

• It is hard to understand the information the doctor or clinic gives me

• I haven’t had enough money or insurance to pay for my visits

• I didn’t have my Medicaid (or state Medicaid name) card

• I didn’t have any transportation to get to the clinic or doctor’s office

• I couldn’t take time off work

• I had no one to take care of my children

• I have had too many other things going on in my life

• I didn’t know I was pregnant

• I didn’t want anyone to know I was pregnant

• I didn’t want prenatal care

• Other:_______________________________________________

9. A personal doctor or nurse is a health professional who knows you well and is familiar with your health history. This can be a general doctor, a specialist doctor, a nurse practitioner, or a physician’s assistant. Do you have one or more persons you think of as your personal doctor or nurse?

Select one only.

• Yes, one person (Go to question 9.1)

• Yes, more than one person (Go to question 9.1)

• No (Go to question 10)

• Don’t know (Go to question 10)

• Declined to answer (Go to question 10)

10. Is there a place that you USUALLY go for care when you are sick or need advice about your health?

Select one only

• Yes (Go to question 10.1)

• No (Go to question 11)

• There is more than one place (go to question 11.1)

• Don't know (Go to question 11)

• Declined to answer (Go to question 11)

10.1 What kind of place do you go to most often when you are sick or you need advice about your health? Is it a doctor’s office, emergency room, hospital outpatient department, clinic or some other place?

Select one answer.

• Doctor’s Office

• Hospital Emergency Room

• Hospital Outpatient Department

• Clinic or Health Center

• Retail Store Clinic or “Minute Clinic”

• School (Nurse’s Office, Athletic Trainer’s Office)

•  Some other place

11. Please tell me what kind of health insurance you have:

Select all that apply.

• Private health insurance through my job, or the job of my husband, partner or parents

• Insurance purchased directly from an insurance company

• Medicaid, Medical Assistance, or any kind of government assistance plan for those with low incomes or a disability

• TRICARE or other military health care

• Indian Health Service

• Other, specify: ___________________

• No insurance

• Don’t know

• Declined to answer

FOLLOW UP

Provided information/education about:

• Importance of regular prenatal care

• Importance of having a regular provider/medical home

• Medicaid eligibility

• Birth spacing

• Breastfeeding

• Feeding your newborn

• Labor and delivery, including premature labor , preparation for C-section

Date ______________

Provided Service:

• Enrolled in Medicaid

Date _____________

Referred for:

• Medicaid enrollment

• OB/GYN provider

• Primary Care Provider

• Prenatal classes

Date_______________

Social Determinants of Health

12. Are you currently married or living with a partner, separated, divorced, widowed, or were you never married?

Select one only.

• Married or living with a partner

• Separated

• Divorced

• Widowed

• Never married

• Declined to answer

13. Are you currently…

STAFF: Please read responses to participant:

Select one only.

• Employed for wages

• Self-employed

• Out of work for 1 year or more

• Out of work for less than 1 year

• A Homemaker

• A Student

• Retired

• Unable to work

DO NOT READ OUT LOUD

• Declined to answer

14. What is your yearly total household income before taxes? Include your income, your husband’s or partner’s income, and any other income you may have received. All information will be kept private and will not affect any services you are now getting.

Select one only.

• Less than $10,000

• $10,000 to less than $15,000

• $15,000 to less than $20,000

• $20,000 to less than $25,000

• $25,000 to less than $35,000

• $35,000 to less than $50,000

• $50,000 or more

• Don’t know

• Declined to answer

15. How many people are supported by this income?

STAFF: Enter number of people.

_____ Adults age 18 or older

_____ Children age 18 or younger

• Don’t know

• Declined to answer

16. The next question is about whether you were able to afford the food you need. Which of these statements best describes the food situation in your household IN THE PAST 12 MONTHS?

STAFF: Please read responses to participant.

Select one only.

• We could always afford to eat good nutritious meals.

• We could always afford enough to eat but not always the kinds of food we should eat.

• Sometimes we could not afford enough to eat.

• Often we could not afford enough to eat.

DO NOT READ OUT LOUD

• Declined to answer

17. What is the Zip Code where you live?

_________________

• Don't Know

• Declined to answer

18. Do you own a place, rent a place, live in public housing, stay with a family member, or are you homeless?

Select one only.

• Owns or shares own home, condominium or apartment (Go to question 19)

• Rents or shares own home or apartment (Go to question 18.1)

• Lives in public housing (receives rental assistance, such as Section 8) (Go to question 18.1)

• Lives with parent or family member (Go to question 18.1)

• Homeless (Go to question 18.2)

• Some other arrangement (Please specify): ___________________ (Go to question 18.1)

• Declined to answer (Go to question 19)

18.1 Is this place a regular place to stay? By “a regular place to stay” I am referring to a house, apartment, room, or other housing where you could stay 30 days in a row or more in the same place.

Select one only.

• Yes (Go to question 19)

• No (Go to question 19)

• Don’t know (Go to question 19)

• Declined to answer

(Go to question 19)

18.2. Do you share housing with someone, live in an emergency or transition shelter, or have some other living arrangement?

• Homeless and shares housing with someone

• Lives in an emergency or transition shelter

• Some other arrangement: ________________

• Declined to answer

19. Do you have any housing concerns?

Select one only.

• Yes (Go to question 19.1)

• No (Go to question 20)

• Don’t know (Go to question 20)

• Declined to answer (Go to question 20)

19.1. What issues concern you about your housing situation?

Select all that apply.

• Received an eviction notice

• Non-payment of rent or past due rent

• Unable to pay future rent because lost housing subsidy, job, or other income source

• Non-payment of utilities or utility shut-off

• Housekeeping concerns (failure to maintain cleanliness of the unit)

• Housing is or will be condemned

• Friend or family member being evicted or threatened with eviction

• Threat of abuse by partner, family member, or other

• Being discharged or service is being terminated

• Personal conflict with others

• Other health or safety concerns

• Other lease violation(s) (please describe):______________________

• Other (please describe):______________________

• Don’t know

• Declined to answer

20. I am going to read a list of services. Please tell me if you are receiving the service, if you have applied for the service and are waiting to find out if you will receive services, if you need services, or if you don’t need services. I want to remind you that I ask these questions so we can provide the best services for your family.

STAFF: Please read each of the following services to participant and enter an answer for each service.

	Receiving	Have applied for	Need	Do not need	Not applicable	Declined to answer
Childcare voucher
Emergency Aid to the Elderly, Disabled, and Children (EAEDC)
Food stamps/SNAP
Heating assistance
Immigration services
Legal services
Public housing
Section 8 Voucher
Social Security Disability Insurance (SSDI)
Social Security Income (SSI)
Transitional Aid to Families with Dependent Children (TAFDC)
Temporary Assistance to Needy Families (TANF)
Tribal Housing
Utility Assistance
Nutrition Supplemental Program for Women Infants and Children (WIC)
Other (please specify)

21. Do you currently have an open case with Child Protective Services?

Select one only.

• Yes

• No

• Don’t know

• Declined to answer

FOLLOW UP

Provided information/education about: Childcare voucher Emergency Aid to the Elderly, Disabled, and Children (EAEDC) Food stamps/SNAP Heating assistance Immigration services Legal services Public housing Section 8 Voucher Social Security Disability Insurance (SSDI) Social Security Income (SSI) Transitional Aid to Families with Dependent Children (TAFDC) Temporary Assistance to Needy Families (TANF) Tribal Housing Utility Assistance Nutrition Supplemental Program for Women Infants and Children (WIC) Other (please specify) Date _______________

Referral made for: Childcare voucher Emergency Aid to the Elderly, Disabled, and Children (EAEDC) Food stamps/SNAP Heating assistance Immigration services Legal services Public housing Section 8 Voucher Social Security Disability Insurance (SSDI) Social Security Income (SSI) Transitional Aid to Families with Dependent Children (TAFDC) Temporary Assistance to Needy Families (TANF) Tribal Housing Utility Assistance Nutrition Supplemental Program for Women Infants and Children (WIC) Other (please specify) Date _______________

Neighborhood and Community

22. Now I am going to ask you a few questions about your neighborhood or community. Please tell me if you agree or disagree with each of these statements

STAFF: Please read each of the following statements to participant and enter an answer for each statement.

Q#	Statement	Agree	Disagree	Don’t know	Declined to answer
22.1	People in this neighborhood or community help each other out
22.2	We watch out for each other’s children in this neighborhood or community

23. How often do you feel safe in your community or neighborhood? Would you say never, sometimes, usually, or always?

Select one only.

• Never

• Sometimes

• Usually

• Always

• Declined to answer

24. How often do you participate in school, community, or neighborhood activities? Would you say daily, weekly, monthly, a few times a year, less than once a year, or never?

Select one only.

• Daily

• Weekly

• Monthly

• A few times a year

• Less than once a year

• Never

• Declined to answer

25. How often do you get together or talk with family, friends or neighbors? Would you say daily, weekly, monthly, a few times a year, less than once a year or never?

Select one only.

• Daily

• Weekly

• Monthly

• A few times a year

• Less than once a year

• Never

• Declined to answer

Health and Health History

26. In general, would you say that your overall health is excellent, very good, good, fair, or poor?

Select one only.

• Excellent

• Very good

• Good

• Fair

• Poor

• Don’t know

• Declined to answer

27. In general, would you say that your mental and emotional health is excellent, very good, good, fair, or poor?

Select one only.

• Excellent

• Very good

• Good

• Fair

• Poor

• Don’t know

• Declined to answer

28.1 How tall are you without shoes?

Please enter height in feet and inches.

____________Feet ____________ Inches

• Don’t Know

• Declined to answer

28.2 Just before you got pregnant, how much did you weigh?

Please enter weight in pounds.

____________ Pounds

• Don’t Know

• Declined to answer

28.3 How much do you weigh now?

Please enter weight in pounds.

____________ Pounds

• Don’t Know

• Declined to answer

29. Has a healthcare provider ever told you that you have any of the following medical conditions?

STAFF: Select one response only for each question. If participant has a condition, please ask if they currently have this condition.

Asthma (breathing problems/wheezing)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Autoimmune disease [Lupus (SLE), Rheumatoid Arthritis (RA), etc.]

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Cancer

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Cardiovascular disease (heart problems)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Depression or other mental health conditions (anxiety, bipolar)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Diabetes (high blood sugar)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Gestational Diabetes

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Eating disorders (anorexia/bulimia)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

High blood pressure

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Iron Deficiency Anemia

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

PKU (phenylketonuria)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Renal disease (kidney problems)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Seizure disorders (Epilepsy)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Sickle Cell

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Thrombophilia (blood clots)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Thyroid disease – hypo/hyper (overactive or underactive thyroid)

• Yes

• No

• Don’t know

• Declined to answer

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

Other____________________________

If yes, ask: Is this something you have currently?

• Yes

• No

• Don’t know

• Declined to answer

STAFF: If participant currently has any of the above conditions, go to question 29.1.
If participant does not have any of the above conditions, go to question 30.

29.1 Please tell me which condition or conditions you were seen for by a healthcare provider in the past 6 months.

Select all that apply.

• Asthma (Breathing problems/wheezing)

• Autoimmune disease (such as lupus (SLE), Rheumatoid Arthritis (RA))

• Cancer

• Cardiovascular disease (Heart problems)

• Depression or other mental health conditions (anxiety, bipolar)

• Diabetes (High blood sugar)

• Gestational diabetes

• Eating disorders (Anorexia/bulimia)

• High Blood Pressure

• PKU (phenylketonuria)

• Renal disease (Kidney problems)

• Seizure disorders (Epilepsy)

• Sickle Cell

• Thrombophilia (Blood Clots)

• Thyroid disease—(Hypo/hyper—overactive or underactive thyroid)

• None

• Declined

30. Are you currently having any pain?

Select only one.

• Yes

• No

• Declined to answer

31. Are you taking any of the following medications? We are asking about these medications because they are known to have an impact on the fetus.

STAFF: ask participant specifically about each medication below, and enter a response for each medication.

Are you taking any:	Yes	No	Don’t know	Declined to answer
Pain medications (such as morphine, codeine, oxycodone, Vicodin, or methadone)
Blood Thinners (such as Coumadin, heparin, or Lovenox)
Male Hormones (such as testosterone)
Antibiotics (such as tetracycline, doxycycline, Flagyl or streptomycin, trimethoprim, Bactrim, Septra)
Seizure or Epilepsy medications (such as valproate, Dilantin or Depakote)
Acne medications  (such as Accutane, Retin-A)
High Blood Pressure medications (ace inhibitors such as Capoten, Vasotec, Lotensin)
High Cholesterol medications (statins, such as Lipitor, Pravachol, Zocor, Mevacor)
Antidepressants (such as lithium, Paxil)

32. Does your provider know all the medications that you are taking? Please tell me for prescribed as well as over the counter medications.

Select only one.

• Yes

• No

• Don’t know

• Declined to answer

33. During the past month, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?

Select only one.

• I did not take a multivitamin, prenatal vitamin or folic acid vitamin at all

• 1 to 3 times a week

• 4 to 6 times a week

• Every day of the week

• Don’t Know

• Declined to answer

34. When was the last time you were tested for sexually transmitted diseases or sexually transmitted infections?

STAFF: Please read each sexually transmitted disease/infection to participant, and enter one response for each one.

Sexually Transmitted Disease/Infection	Less than 6 months ago	6 months to 1 year ago	More than 1 year ago	Never	Don’t know	Declined to answer
Chlamydia
Gonorrhea
Herpes Simplex
HIV
Syphilis
Other:

35. Have you ever been diagnosed with any of the following infectious diseases?

STAFF: Please read each infectious disease to participant, and enter one response for each infectious disease.

Infectious Disease	Yes	No	Don’t know	Declined to answer
Toxoplasmosis
Tuberculosis
Cytomegalovirus
Hepatitis B or C
Zika
Chlamydia
Gonorrhea
Herpes Simplex
HIV
Syphilis
Other:

36. How long ago did you last have your teeth cleaned by a dentist/hygienist? Would you say less than six months ago, six months to a year ago, more than a year ago, or never?

Select one only.

• Less than six months ago

• Six months to one year ago

• More than one year ago

• Never

• Don’t know

• Declined to answer

37. How often do you wear a seatbelt when you ride in a car, truck or van?

Select one only.

• Never

• Seldom

• Always

• Not applicable (doesn’t ride in car, truck or van)

• Don’t know

• Declined to answer

FOLLOW UP

Provided information/education about:

• Keeping a healthy pregnancy weight including how much weight to gain during pregnancy

• Nutrition

• Exercise

• Importance of taking prenatal vitamins/ folic acid vitamin

• Getting vaccines

• Getting flu shot

• Travel advisory

• Sexually transmitted infections

• Keeping teeth healthy

• Health risks during pregnancy

• Seat belt use during pregnancy

Date ______________

Provided:

• Nutritional counseling

• Immunizations: Please specify___________________________________________

• Pain assessment

Date ______________

Referred to:

• Primary Care Provider

• Nutritionist

• Dentist

• Other: Please specify_____________

Date ______________

Mental Health

38. Over the past two weeks, how often have you experienced any of the following, would you say, never, several days, more than half the days, or nearly every day?

STAFF: Read each problem to participant, and enter one score for each question.

Q#	Problem	Not at all	Several Days	More than half the days	Nearly every day	Score
38.1	Little interest or pleasure in doing things	0	1	2	3
38.2	Feeling down, depressed, or hopeless	0	1	2	3
	Total Score

NOTE: Enter the number that matches the participant’s answer in the last column, and add the answers for both together to get the final score. If the final score is more than 3, further assessment is needed.

FOLLOW UP

Provided information / education about:

• Postpartum depression or “Baby Blues”

• Local resources for depression

Date ______________

Provided:

• Further assessment using evidence-based tool such as PHQ-9 or Edinburgh Postnatal Depression Screen (EPDS)

• Provided counseling

Date ______________

Referred to:

• Mental health center

• Primary Care Provider

• Other: Please specify_______________________________________________________

Date ______________

Substance Use

If it’s okay with you, I’d like to ask you a few questions that will help me give you better care. The questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you have taken them for reasons or in doses other than prescribed. I’ll also ask you about illicit or illegal drug use.

39. In the past 12 months, how often have you used the following?

STAFF: Read substances and answers to participant and enter one response for each substance.

Substance	Never	Once or Twice Monthly	Weekly	Daily or Almost Daily	Declined to answer
Alcohol (4 or more drinks per day)
Tobacco Products (including cigarettes, chewing tobacco, snuff, iqmik, or other tobacco products like snus Camel Snus, orbs, e-cigarettes, lozenges, cigars, or hookah)
Mood-altering Drugs (including marijuana)
Prescription Drugs for Non-Medical Reasons
Illegal Drugs (marijuana, cocaine, crack, heroin, uppers/crank/meth, PCP, diet pills, LSD)

40. Do you currently smoke any cigarettes or use any tobacco products?

Select one only

• Yes

• No

• Declined to answer

41. Which of the following statements best describes the rules about smoking inside your home now?

STAFF: Please read responses to participant.

Select one only.

• No one is allowed to smoke anywhere inside my home

• Smoking is allowed in some rooms or at some times

• Smoking is permitted anywhere inside my home

DO NOT READ OUT LOUD:

• Declined to answer

42. Which of the following statements would you say best describes your current alcohol use, INCLUDING beer and wine coolers?

STAFF: Please read the following responses to participant.

Select one only

• I drink alcohol regularly now – about the same as before finding out I was pregnant

• I drink alcohol regularly now but I’ve cut down since I found out I was pregnant

• I drink alcohol every once in a while

• I have quit drinking alcohol since I found out I was pregnant

• I wasn’t drinking alcohol around the time I found out I was pregnant and I don’t currently drink

DO NOT READ OUT LOUD:

• Don’t know

• Declined to answer

FOLLOW UP
Provided information/education about: Potential effects on pregnancy of tobacco Potential effects on pregnancy of alcohol Potential effects on pregnancy of drug use Tobacco cessation Date__________________	Provided further screening/assessment: TWEAK, T-ACE, or 4 Ps (for “Yes” to 1 or more days of heavy drinking [for women, 4 or more drinks per day]) NIDA-Modified ASSIST (for any use of illegal or prescription drug use for non-medical reasons) Provided Brief Intervention Date____________	Referred to: Tobacco Quit Line Behavioral Health Provider Primary Care Provider Substance abuse treatment program Other: Please specify___________ Date__________________

Personal Safety

43. We are concerned about the safety of all participants. Please answer the following questions about experiences that you may have had during the last 12 months so that we can help you if needed.

STAFF: Please read each question to participant and enter one response for each question.

Q#	During the past 12 months…	Yes	No	Declined to Answer
43.1	Did your husband or partner threaten or make you feel unsafe in some way?
43.2	Were you frightened for your safety or your family’s safety because of the anger or threats of your husband or partner?
43.3	Did your husband or partner try to control your daily activities, for example, control who you could talk to or where you could go?
43.4	Did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?
43.5	Did your husband or partner force you to take part in touching or any sexual activity when you did not want to?
43.6	Did anyone else physically hurt you in any way?

44. Do you keep guns in your home?

Select one only

• Yes

• No

• Declined to answer

FOLLOW UP

Provided information/ education about:

• What to do if you have or someone you know has a partner that hurts them physically

• Gun safety

Date______________

• Referred to local domestic violence program _______________________________

Date _______________

Stress and Discrimination

Stress is something we’ve all felt, and is often part of our daily lives. If you experience stress over a prolonged period of time however, it can be harmful to both your mind and body. Stress influences our moods, sense of well-being, behavior and overall health. We ask the following questions to learn what stressors you have in your life and to better understand how to help reduce the stress in your life.

45. This question is about things that may have happened during the past twelve months. For each item, please tell me “no” if it did not happen or “yes” if it did. (It may help to look at the calendar when you answer these questions).

STAFF: Read each event to participant and enter one response for each event.

Q#	Event	Yes	No
45.1	A close family member was very sick and had to go into the hospital
45.2	I got separated or divorced from my husband or partner
45.3	I moved to a new address
45.4	I was homeless or had to sleep outside, in a car, or in a shelter
45.5	My husband or partner/parent or guardian lost his or her job
45.6	I lost my job even though I wanted to go on working
45.7	My husband, partner, parent, guardian or I had a cut in work hours or pay.
45.8	I was apart from my husband or partner/parent or guardian due to military deployment or extended work-related travel
45.9	I argued with my husband or partner/parent or guardian more than usual
45.10	My husband or partner/parent or guardian said he or she didn’t want me to be pregnant
45.11	I had problems paying the rent, mortgage, or other bills
45.12	My husband, partner, parent or guardian or I went to jail
45.13	Someone very close to me had a problem with drinking or drugs
45.14	Someone very close to me died

46. The next set of questions asks you about how other people have treated you. In your day-to-day life, how often have any of the following things happened to you? Would you say almost every day, at least once a week, a few times a year, less than once a year, or never?

STAFF: Read each treatment below to participant and enter one response for each treatment.

Q#	Treatment	Almost every day	At least once a week	A few times a month	A few times a year	Less than once a year	Never	Declined to answer
46.1	You are treated with less courtesy or respect than other people.
46.2	You receive poorer service than other people at restaurants, stores, or social services.
46.3	People act as if they think you are not smart.
46.4	People act as if they are afraid of you.
46.5	You are threatened or harassed.

STAFF:

If participant answers “a few times a year” or more frequently to any of the above, go to question 47.

If participant answers “less than once a year”, “never”, or declines to answer to all the above, go to question 48.

47. What do you think is the main reason for these experiences?

Select only one.

• Your ancestry or national origins

• Your gender

• Your race

• Your age

• Your religion

• Your height

• Your weight

• Some other aspect of your physical appearance

• Your sexual orientation

• Your education or income level

• Your shade of skin color

• Physical Disability

• Other, please specify: ______________________________________________________

• Don’t know

• Declined to answer

FOLLOW UP

• Provided information/ education about resources for stress management

Date _______________

• Provided counseling on stress management

Date _______________

Referred to:

• Mental Health Center

• Primary Care Provider

• Other: Please specify_________________

Date _______________

Social Support / Father or Partner Involvement

People sometimes look to others for companionship, assistance, or other types of support. These questions ask you about the types of support that would be available to you if you needed it. If you are not sure which answer to select, please choose the one answer that comes closest to describing it.

48. For the following questions your response options are the following; none of the time, a little of the time, some of the time, most of the time or all of the time;

If you needed it, how often is someone available to…

STAFF: Read each support task to participant, and select only one response for each support task.

Q#	Support Task	All of the time	Most of the time	Some of the time	A little of the time	None of the time
48.1	Provide temporary financial support?
48.2	Do something enjoyable with you?
48.3	Help with daily chores?
48.4	Help you if you were sick?
48.5	Turn to for suggestions about how to deal with a personal problem?

49. Would you describe your partner or the father of this baby as:

Select only one.

STAFF: Please read responses to participant.

• Involved in my pregnancy and supportive of me (Go to question 49.1)

• Involved but not supportive of me (Go to question 49.1)

• Aware that I’m pregnant but not involved (Go to question 50)

• Not aware that I’m pregnant (Go to question 50)

DO NOT READ OUT LOUD

• Declined to answer (Go to question 50)

49.1. What is your partner’s or the father of your baby’s role in your life?

Select all that apply.

• Partner or father of baby is deceased 

• Partner or father of baby is incarcerated

• Assists with housework and/or runs errands (ex: grocery shopping)

• Attends prenatal appointments and/or childbirth classes

• Provides emotional support

• Provides financial support

• Partner or father of baby plays no role / is not involved

• Other (please specify): __________________________

• Declined to answer

FOLLOW UP

• Provided information/education about importance of social supports

Date________________

Referral made to:

• Social Worker

• Parent help line

• Parent support group

• Other: Please specify______________________

Date________________

Reproductive Life Planning

We have a few questions about your thoughts about having more children. This information will help us support you in making decisions about whether and when you might have more children.

50. Do you plan to have any more children after this baby is born?

Select only one.

• Yes (Go to question 50.1)

• No (Go to question 51)

• Don’t know (Go to question 51)

• Declined to answer(Go to question 51)

50.1 How many children would you like to have?

Please enter the number of children.

_____________Children (Go to question 50.2)

• Don’t know (Go to question 50.2)

• Declined to answer (Go to question 50.2)

50.2 How long would you like to wait until you become pregnant?

Select only one.

• 1 year -17 months

• 18 months to 2 years

• More than 2 years

• Don’t know

• Declined to answer

51. Do you and your partner have a method of birth control that you plan to use until you are ready to become pregnant again?

Select only one.

• Yes

• No

• Don’t know

• Declined to answer

51.1 How sure are you that you will be able to use this method without any problems- not at all confident, somewhat confident, or very confident?

Select only one.

• Not at all confident

• Somewhat confident

• Very Confident

• Don’t know

• Declined to answer

FOLLOW UP

• Provided information/education about birth control or family planning/birth spacing

Date ___________

• Provided counseling about family planning

• Provided birth control

Date ___________

• Referred for birth control

  • Primary Care Provider

  • Planned Parenthood

  • Other: please specify ______________________

Date ___________

The Healthy Start Prenatal Screening Tool is Complete

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