Family Road Healthy Start Preliminary Risk Screening Tool

Yes
No
Miscarriages
Abortions
Stillbirths
Low Birth Weight Births (> 5lbs 6oz)
Preterm Births (37 weeks)
Infant Death (28 days or less)

Have you previously been treated for any of the conditions below or are you currently being treated for any of these conditions:

Diabetes
High Blood Pressure
Sexually Transmitted Diseases/Infections
Mental Health Counseling
High Risk Prenatal Care
HIV/AIDS
Depression
Diagnosis of psychiatric condition
(Please Select All that Apply)
Diabetes
High Blood Pressure
Sexually Transmitted diseases/infections
Mental Health counseling
High Risk Prenatal Care
HIV/AIDS
Depression
Diagnosis of psychiatric condition
(Please select all the apply)
Earlier
Later
Not at all
No change
Not pregnant
Yes
No
Yes
No
Smoked Cigarettes
Drank alcohol
Used drugs
(Please select all the apply )
 

Networks & Memberships