Obstetrical Needs Assessment Form

 Member Information	Member ID Number:

Last Name: 	First Name:	MI:	DOB (mm/dd/yyyy):	Telephone Number:	
Address:	City, State, Zip Code:	
Email:	Date of initial prenatal visit/Diagnosis date:	Completion date of pregnancy form:	
 Pregnancy Information and History 	

LMP

Gestational age at first visit

EDC

Gravida

Para

Pre-term

Living

Abortions

 	 Spontaneous:	Induced:
Risk Factors (past or current)	Active Medical Conditions	Social, Economic and Lifestyle Factors
No Risk Factors		None		No Risk Factors Diabetes/GDM/LGA baby	Advanced maternal age	Behavioral health condition DVT/PT	Asthma
Eclampsia/Pre-eclampsia	Auto-immune disease(s)	Domestic violence
Fetal congenital anomaly or disorder	Housing issues
Fetal death		BMI (low or high):	Identified social, economic and lifestyle Second trimester	Third trimester	Hepatitis
Hypertension/GHTN	HIV	Intellectual impairment
Incompetent cervix	Seizure disorder:	Lack of support system
IUGR/SGA baby	Thyroid disease - treated?	Literacy issues
Late and/or inconsistent prenatal care		Yes	No	Mental/physical/sexual abuse Low birth weight < 2500 grams	Other (specify):		(current or history of): Multiple gestation
Placenta abnormalities	Postpartum depression
Abruption	Previa	Smoking/tobacco use; individualized Premature ROM		intervention offered?
Pre-term (specify gestational age)	Yes	No
Delivery:	Substance abuse:
Labor:	Alcohol:
Renal Disease	Drug abuse:
Sickle cell disease/trait	Teen pregnancy:
Abnormal ultrasound:	Other (specify):
Uterine abnormality: Other:
STI History	Current Medications
Screen Date  Negative Positive	No Medications
HIV:			Please list:
Syphilis: Gonorrhea: Chlamydia:
Provider Information
Provider Name:	Tax ID Number:	Phone Number:	Fax Number:	Delivery Hospital:

Address:	City, State, Zip Code:

Provider (MD/DO/APRN/PA):  	    Date: _______________

Please fax form to the member’s plan:	     Nebraska Total Care 				844-843-3890
     Healthy Blue						800-964-3627              
    UnitedHealthcare Community Plan of Nebraska 	402-445-5730