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Prenatal Care Coordination Services Handbook
Appendix 9

Instructions for Completing the Pregnancy Questionnaire

As much as possible, please ask the questions exactly as they are stated on the Pregnancy Questionnaire. This is especially important when you ask the alcohol-related questions (D.3 through D.9). If the woman appears not to understand what you are asking, you may rephrase the question (except for questions D.3 through D.9). However, please be very careful not to change the meaning of the questions.

You are required to complete and score the entire questionnaire, unless the woman refuses to answer a particular question(s).

Providers may consult the Guidance Manual for Administering the Prenatal Care Coordination Pregnancy Questionnaire for additional, detailed information on administering the questionnaire. Refer to Appendix 16 of this handbook for information on obtaining the manual.

Section A. General Information

The purpose of this section is to identify socio-demographic risk factors.

1. Name and address.
Record the woman’s name and address.
 
2&3.*Date of birth and age.
Verify consistency of answers.
 
4. Medicaid Identification Number.
Record the woman’s Medicaid number.
 
5.* Telephone number.
Check "No phone" if she only has a work number.
 
6. How can we contact you?
Check all that apply.
 
7.* Are you single (never married, separated, divorced, widowed) or married?
If the woman indicates that her marriage is not stable, check single.
 
8. Your race/ethnic origin.
Check the appropriate box.
 
9. Do you speak English?
Check the appropriate box.
 
10.*Do you read English?
Check the appropriate box.
 
11. Are you in a WIC program?
Check the appropriate box.
 
12. What are your sources of income?
Check only those that are consistent sources.
 
13. Are you employed?
If she is both a student and employed, check both.
 
14.*What was the last grade you finished in school? If in school now, do you attend regularly?
Record the last grade completed and check the appropriate box.
 
15.*Have you in the past, or are you currently receiving special education services or exceptional education services?
Check "yes" no matter what type of special or exceptional education service(s) she received or is receiving.
 
16.*Where do you live?
Check the appropriate box.
 
17.*How many times have you moved in the last year?
Include temporary relocations that were not visits. For example, include a three-week stay with a family member/friend while looking for a place to live. Do not include a two-month stay with an ill family member or friend.
 
18. Name, address, and telephone number of parent, guardian, or person to call in an emergency.
Record the information the woman provides.

Section B. About this Pregnancy

The purpose of this section is to obtain information about risk factors related to the adequacy of care and to identify early signs of complications.

1. How "far along" are you now?
Record the information provided.
 
2.* How far along were you when you started seeing a health care provider for prenatal care?
Record the information provided.
 
3.* Have you seen your health care provider at least monthly for this pregnancy?
Check the appropriate box.
 
4.* Did this pregnancy come less than a year after your last pregnancy?
Check the appropriate box.
 
5.* Are you pregnant with more than one baby?
Check "yes" only if a health care provider gave her confirmation.
 
6.* Have you had any early signs of labor?
Check the appropriate box.
 
7.* Have you gone to the emergency room or hospital for this pregnancy?
Check "yes" only if the visit was pregnancy-related.
 
8. Would you like more information or help with any of these things?
Check all that apply. Write down any additional information.

Section C. Medical History

The purpose of this section is to obtain information about the woman’s medical and child bearing history and to identify past or current medical conditions that may influence the outcome of her pregnancy.

1.* Do you have, or have you ever had, any of these conditions?
For the medical conditions, check only if she indicates that a health care provider confirmed the condition.
 
2.* How many times have you been pregnant before this pregnancy?
Record the number of confirmed pregnancies.
 
3.* Have you had any miscarriages?
Record the number of miscarriages.
 
4.* Have you had any abortions?
Record the number of induced abortions.
 
5. Have you had twins or multiple births?
Check the appropriate box.
 
6.* Have you ever had a C-Section?
Check the appropriate box.
 
7.* Were any of your babies born more than 3 weeks early?
Check the appropriate box.
 
8.* Did a doctor ever say you had premature labor that required bed rest, medication, and/or hospitalization?
Check the appropriate box.
 
9.*Have you had a stillborn baby (born dead after 20 weeks), or that died soon after birth?
Check the appropriate box.
 
10.*Did any of your babies weigh less than 5 1/2 pounds at birth?
Check the appropriate box.
 
11.*Did any weigh more than 10 pounds at birth?
Check the appropriate box.
 
12.*Did any stay more than one day in a special care nursery?
Check the appropriate box.
 
13.*When did you start prenatal care during your last pregnancy?
Check the appropriate box.

Section D. Tobacco, Alcohol, Medicines, & Other Drugs

The purpose of this section is to obtain information about the woman’s use of tobacco, alcohol, illicit drugs or medication.

1. During the 3 months before you were pregnant, on average, how many cigarettes did you smoke a day?
Check the appropriate box.
 
2.* On average, how many cigarettes do you smoke a day now?
Check the appropriate box.

Do not rephrase Questions D.3 through D.9.

3.* How many drinks does it take to make you feel high?
"High" is subjective. Accept her interpretation.
 
4.* How much can you hold?
"Hold" is subjective. Accept her interpretation.
 
5.* Have people annoyed you by criticizing your drinking?
Check the appropriate box.
 
6.* Have you ever felt you ought to cut down on your drinking?
Check the appropriate box.
 
7.* Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Check the appropriate box.
 
8.* Since you became pregnant, about how many days in a month do you have 3 or more drinks?
Record the number of days.
 
9. Since you became pregnant, about how many days in a month do you have one or more drinks?
Record the number of days.
 
10. Have you taken any prescription drugs since you became pregnant?
Check the appropriate box.
 
11. Have you taken any over-the-counter drugs since you became pregnant?
Check the appropriate box.
 
12.*Have you ever injected a non-prescribed drug?
Check the appropriate box.
 
13. Number of different persons with whom you shared intravenous drug needles or syringes, or "works" within the last 10 years...last 12 months.
Record the number of persons for each.
 
14.*Do you think any of these persons were infected with HIV (the AIDS virus)?
Check the appropriate box.
 
15.*How often did you smoke marijuana or hash during the 3 months before you found out that you were pregnant?
Check the appropriate box.
 
16.*How often did you use cocaine or crack during the 3 months before you found out that you were pregnant?
Check the appropriate box.
 
17.*How often did you use heroin, speed, acid, amphetamines, PCP, inhalants, etc., during the 3 months before you found out that you were pregnant?
Check the appropriate box.

Section E. Nutrition

The purpose of this section is to obtain information about the woman’s current nutritional status.

1.* How much did you weigh before you became pregnant this time? How tall are you?
Record the woman’s pre-pregnancy weight and height. (To assess and categorize the woman’s pre-pregnancy weight, use the Body Mass Index Grid in the Guidance Manual for Administering the Prenatal Care Coordination Pregnancy Questionnaire.)
 
2.* What do you weigh now?
Record the woman’s weight.
 
3. Have you ever vomited to control your weight or vomited to feel better after eating too much?
Check the appropriate box.
 
4.* Do you vomit often now?
"Often" is subjective. Accept her response.
 
5. Are you having any of the following symptoms now: Nausea, Heartburn, Constipation
Check the appropriate box.
 
6. When you were not pregnant, did you feel that your weight and your body shape were: about right, overweight/too large, underweight/too small?
Check the appropriate alternative.
 
7. Are you on a special diet now?
Check the appropriate box.
 
8.* Do you eat corn starch out of the box, laundry starch, paint chips, lots of ice, clay, dirt or other things that are not food?
Check "yes" if she indicates that she has eaten nonfood items just before or during the pregnancy.
 
9.* During the past month did you miss any meals or not eat when you were hungry because there wasn’t enough food or money to buy food?
Check the appropriate box.
 
10.*Do you have a working stove and refrigerator?
Check "no" if one or the other is not working.

Section F. Relationships

The purpose of this section is to obtain information about the woman’s social support network (husband, partner, parents, other family, friends, and neighbors), her feelings of self-worth, competency, and personal safety.

1.* How do you feel now about being pregnant?
Check the appropriate box.
2.* How does your husband or partner feel now about you being pregnant?
Check the appropriate box.
 
3.* How often did you feel depressed during the last week?
Check the appropriate box.
 
4. How many living children do you have?
Record the number of children.
 
5. How many of them are living in your household now?
Record the number of children living in the household.
 
6.* Within the past 12 months, have any of your children been taken from you?
Check the appropriate box.
 
7.* Have you ever had sexual contact with any of the following: HIV-infected partner, IV drug user, bisexual partner, hemophiliac?
Check the appropriate box.
 
8.* Have you given or received money or drugs for sex?
Check the appropriate box.
 
9.* Does your partner have a problem with alcohol or other drugs?
"Problem" is subjective. Accept her response.
 
10.*Does anyone else in your family have a problem with alcohol or other drugs? What relation is this person to you?
Check the appropriate box. Include persons who are not "blood" relatives but who were raised as relatives.
 
11.*Have you ever been emotionally, verbally, or physically abused by your partner, or someone close to you?
Check the appropriate box.
 
12. Have you been hit, slapped, kicked, or otherwise physically hurt by your partner or someone close to you?
Check the appropriate box.
 
13.*Since you have been pregnant, were you hit, slapped, or kicked, or otherwise physically hurt by someone?
Check the appropriate box.

Note: Individuals whose employment brings them into contact with children under the age of 18 are required by law (Wisconsin Child Abuse Act) to report, to their county child protection/ social service agency, any suspected abuse or neglect or a belief that abuse or neglect will occur.

14.*Has anyone forced you to have sexual contact?
Check the appropriate box.
 
15. Have other family members been sexually assaulted or abused?
Check the appropriate box.
 
16.*Are you afraid of your partner or anyone else?
Check the appropriate box.
 
17. Is there a gun in your home?
Check the appropriate box.
 
18.*Is there someone you can talk to when you have a problem?
Check "yes" if the person is a consistent source. For example, their hairdresser or the mail carrier would not count.
 
19.*How many people can you really count on when you need help?
Check the appropriate box.
 
20. What do you do to deal with your problems?
Record the response.
This open-ended question provides the woman with an opportunity to share her strengths. Understanding her strengths will help you develop a realistic care plan with her.

Section G. Worries

The purpose of this section is to identify areas of worry for the pregnant woman.

1.* Which of these things worry you a lot?
Check only those items that are significant problems.
 
2.* How often do you have problems getting transportation?
This question relates to transportation to carry out activities of daily living, including:

Additional worries.
Allow the woman to identify any additional concerns. Although answers are not scored, this will allow both of you to understand all the issues she is facing during her pregnancy.

 

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