The Health Plan of the Upper Ohio Valley > Member Services > Member Forms

Member Services > Member Forms > Prenatal Risk Screen

Health Plan Members please complete the following form:

* Required Fields

Physician/RN Comments:

Member Name*
Member ID (must be 9 characters)*
Date of Birth
Your Due Date
Address
City, State
Zip Code
Phone Number*
Email Address
Obstetrician*
Provider Phone Number
Did you ever have a C section?	Yes
Did you ever have a miscarriage?	Yes
Did you ever have a baby who weighed less than 5lb. 8oz.?	Yes
Did you ever have a baby born more than 3 weeks early?	Yes
Did your baby stay in the hospital after you were discharged?	Yes
Preterm & Medical Risk Factors (check each factor that applies)
Current episode of preterm labor	Yes
Previous Preterm labor	Yes
Multiple gestation this pregnancy	Yes
Known history of cocaine, marijuana, or street drugs this pregnancy	Yes
Use of tobacco products since last menstrual period	Yes
Use of any beer, wine, wine coolers, or liquor since last menstrual period	Yes
Incompetent cervix with cerclage	Yes
Uterine abnormality	Yes
Chronic hypertension	Yes
Diabetes mellitus at conception, insulin dependent	Yes
Diabetes mellitus at conception, non-insulin dependent	Yes
Infertility Meds/Assisted Reproductive Technology to achieve pregnancy	Yes
Other cause for medical concern (explain in comments)	Yes