PRIORITY HEALTH SERVICES
INFANT RISK SCREENING TOOL
MATERNAL INFANT HEALTH PROGRAM
INFANT AND CAREGIVER INFORMATION
Infant Name
Infant Date of Birth
Infant Medicaid ID #
Street Address
City, State, Zip
Mother/Caregiver Name
Mother/Caregiver Phone Number
Additional Contact Person
Alternate Phone Number
MEDICAL CARE PROVIDER INFORMATION
Medical Care Provider Name
Medical Care Provider Street Address
Medicaid Health Provider City, State, Zip
Medical Care Provider Phone Number
Medicaid Health Plan :Office Only
Referral Source
NEED FOR ASSISTANCE TO CARE FOR YOUR INFANT
Do you have trouble understanding instructions from Dr.?
N/A
YES
NO
Do you have any experience in taking card of a baby
N/A
YES
NO
Do you want to learn more about taking care of your baby?
N/A
YES
NO
Do you have any problems taking care of yourself or your baby?
N/A
YES
NO
Where do you live?
Rent Apt/Home
Own Home
With Relatives
Shelter
Car
Motel
Do you have trouble reading?
N/A
YES
NO
Is English your first language?
N/A
YES
NO
What is the last grade you finished in school?
Do you need a ride to get to medical appointments?
N/A
YES
NO
Have you ever missed a medical appointment because of a ride?
N/A
YES
NO
How do you get there?
Car
Bus/Taxi
Other
Do you have a car seat?
N/A
YES
NO
Do you have a bassinet?
N/A
YES
NO
FEEDING THE BABY
How often do you feed your baby in a day?
Do you :
Breast Feed
Bottle Feed
Are you worried about your baby's weight?
N/A
YES
NO
Are you feeding your baby:
Cereal
Fruits
Vegetables
Does your baby have any health problems that worry you?
MOTHER WITH COGNITIVE, EMOTIONAL OR MENTAL NEEDS
Do you feel stressed?
N/A
YES
NO
Do you have a history of postpartum depression?
N/A
YES
NO
Are you worried about your mental or emotional health?
N/A
YES
NO
LOW BIRTH WEIGHT
What was the birth weight of your baby?
Above 5lbs 5oz
Below 5lbs 5oz
What week of the pregnancy was your baby born?
FAMILY SUPPORT
Who can you count on for support?
( Use Shift Key to select more than one option )
SELECT
Babys Father Yes
Babys Father No
A Parent No
A Friend Yes
A Friend No
A Parent Yes
Who do you live with?
How many times have you been pregnant?
What are the ages of your children at home?
Who supported you during pregnancy?
HOMELESS DANGEROUS LIVING SITUATION
Do you and your baby feel safe in your home?
N/A
YES
NO
Do you have trouble paying your bills?
N/A
YES
NO
Do you have enough money to buy food?
N/A
YES
NO
FAMILY HISTORY OF MOTHER'S ABUSE/NEGLECT
Do you worry about someone you know mistreating you?
N/A
YES
NO
Do you worry about anyone you know mistreating your child or children?
N/A
YES
NO
Have you ever been abused?
N/A
YES
NO
Have you ever been neglected?
N/A
YES
NO
USE OF ALCOHOL, STREET DRUGS OR TOBACCO PRODUCTS
Do you smoke?
N/A
YES
NO
Do you drink alcohol (beer, wine, liquor) when you are pregnant?
N/A
YES
NO
Do you use drugs not prescribed by a doctor?
N/A
YES
NO
Does someone in your household use drugs?
N/A
YES
NO
IS THERE ANYTHING ELSE YOU WANT TO TELL US OR THAT WE CAN HELP YOU WITH?
FORM COMPLETED BY: *
DATE:
EMAIL:
*
PHONE: