PRECONCEPTION HEALTH SCREENING & TUNE-UP FORM
Are you planning to become pregnant in the next six months? YES NO
PLEASE CHECK THE BOX AND FILL IN (OR CIRCLE) OTHER INFORMATION THAT APPLIES TO YOU. DIET & EXERCISE MEDICAL/FAMILY HISTORY Do you currently have or have ever had.
Do you follow a special diet (vegetarian, diabetic, other)?
Do you eat raw or under cooked food (meat, fish, other)?
Do you have current/past problems with eating disorders?
Do you take other vitamins daily?__Multivitamin __Vitamin A
Other:_________________________________________
Do you take dietary supplements?__Black Cohosh __Pennyroyal
Other:_____________________________________________
Do you exercise? Type:_______________________________
Frequency:_______________________________________
Which do you drink: ___coffee ___tea ___cola ___milk ___water
Other________________________________________________
Depression or other mental health problems
What do you consider a healthy weight for you? ______________________
Surgeries ___________________________________
Tune-Up Suggestions:
Other conditions_______________________________
• Work toward a healthy weight by exercising on a regular/routine basis. Have you ever been vaccinated for:
• All women of childbearing age should take a multivitamin that contains folic acid. Folic acid can
reduce the chance of certain birth defects, especially when it’s taken before you get pregnant.
• If you are on a special diet, and plan on having a baby, talk to your health care provider about
how to modify your diet during pregnancy. LIFESTYLE Tune-Up Suggestions:
• Be sure your immunizations are up to date before you consider becoming pregnant.
• Any medical conditions or problems should be discussed with your health care provider
Do you smoke cigarettes or use other tobacco products?
If yes, how many cigarettes per day?______________________
• Tell your health care provider if you are diabetic, or have your blood sugar checked
regularly. High blood sugar can lead to birth defects, but it can be controlled.
If yes, what kind? __________________________________
MEDICATIONS/DRUGS
How often?__________________How much?_____________
Do you use non-prescribed (street) drugs?
Are you taking prescribed drugs (Accutane, valproic acid,
Circle any that apply (cocaine, heroin, ecstasy, meth/ice, marijuana, other)
blood thinners)? If yes, list:_______________________
List:___________________________________________
Do you work or live near possible hazards (chemicals, X-ray or
Are you taking non-prescribed (over-the-counter) drugs?
other radiation, lead)? If yes, ____________________________
If yes, list:__________________________________
Do you use saunas, tanning beds, or hot tubs?
What kind of work do you do?_________________________________
____________________________________________________
Do you get injectable contraceptives or shots for birth control?
Tune-Up Suggestions:
Do you use any herbal remedies or alternative medicine?
• Visit your health care provider regularly to maintain your overall health.
If yes, list;__________________________________
• Have regular dental checkups, especially if you are pregnant or planning to become
pregnant. Gum disease is associated with pre-term labor. Tune-Up Suggestions:
• If you smoke, drink or use drugs, get the help you need to quit prior to pregnancy.
Talk to your health care provider about:
Smoking during pregnancy is associated with low birth weight infants and other poor
• When to stop taking birth control if you’re planning to become pregnant.
birth outcomes. Alcohol can cause fetal alcohol syndrome, a devastating physical and
• Any medications you’re taking whether over-the-counter or prescription. Certain medications can cause birth defects.
• Herbal remedies you may be taking. Some herbs may not be safe during pregnancy. ESCAMBIA COUNTY HEALTHY START COALITION, INC. PRECONCEPTION HEALTH SCREENING & TUNE-UP FORM WOMEN’S HEALTH GENETICS DOES YOUR FAMILY OR YOUR PARTNER’S FAMILY HAVE A HISTORY OF:
Do you have any problems with your menstrual cycle?
PARTNER’S FAMILY
Have you had surgery on your uterus, cervix, ovaries or tubes?
Have you ever had HPV, genital warts or chlamydia?
How many times have you been pregnant?___________
If you have been pregnant before:
What was/were the outcome(s)?__________________________________
______________________________________________________
Did you have difficulty getting pregnant the last time?
Did your mother take the hormone DES during pregnancy?
Have you ever been treated for a sexually transmitted infection
(Genital herpes, gonorrhea, syphilis, HIV, AIDS, other)?
Your ethnic background is:______________________
If yes, list treatments: ________________________________
______________________________________
______________________________________________
Your partner’s ethnic background is:________________Tune-Up Suggestions: ______________________________________
• If you are trying to get pregnant, talk to your health care provider about the best timing
Tune-Up Suggestions:
and/or frequency of intercourse for you to conceive.
• Your family’s medical history is important to know prior to
• STIs (sexually transmitted infections) are frequently unrecognized (chlamydia,
gonorrhea, herpes, genital warts, HIV).
• Genetic counseling can identify conditions which may affect your baby,
• Testing is easy and available. Talk to your health care provider if you have any
and gives you an opportunity to make important decisions. HOME ENVIRONMENT OTHER CONCERNS
Do you feel emotionally supported at home?
Is there anything else you’d like your health care
Do you have help from relatives or friends if needed?
provider to know? Write them below.
Do you feel you have serious money/financial worries?Are you in a stable relationship?
Does anyone threaten or physically hurt you?Do you have pets (cats, rodents, exotic animals)?
If yes, list:______________________________________
____________________________________________ Do you have any contact with soil, cat litter or sandboxes?
Are there any questions you‘d like to ask your Baby preparation (planning for your baby): health care provider? Write them below.
Do you have a crib for a baby to sleep in?Do you need any baby items?
Can you afford to purchase a crib & diapers?
Tune-Up Suggestions:
• A baby brings lots of new responsibilities. Here are some things you can be thinking about if you’re considering pregnancy:
o Will the baby have clothes and other necessities?
o Who will care for the baby if you return to work?
Tune-Up Suggestions:
• You should feel free to talk to your health care provider about any fears or concerns you have!
IMPORTANT: You may or may not be planning to get pregnant right away, but a check on your health and that of your
partner before a pregnancy begins is an important first step toward having a healthy pregnancy and health baby, when and if
the time comes. Please use this completed form to guide your discussions with your health care provider.
PRECONCEPTION HEALTH SCREENING & TUNE-UP FORM