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Healthy Start Pregnancy History Screening Tool Name: August 2016OMB #: 09150338 Expiration Date: 11/30/2019Completed by: Date of Administration: This screening tool should be completed with all women

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How to fill out health start pregnancy history

01

To fill out the Health Start Pregnancy History, follow these steps:

02

Begin by gathering all necessary personal and medical information related to your pregnancy.

03

Start with basic demographic details such as your name, date of birth, address, and contact information.

04

Provide information about your medical history, including any pre-existing conditions, allergies, and medications you are currently taking.

05

Fill in details about your prenatal care, including the name of your healthcare provider, the date of your first prenatal visit, and any tests or procedures you have undergone.

06

Answer questions related to your lifestyle and habits, such as smoking, alcohol consumption, and exercise routine.

07

Provide information about your family medical history, especially if there is a history of genetic disorders or pregnancy complications.

08

Finally, review your answers and make sure all the information is accurate and complete. Sign and date the form before submitting it.

Who needs health start pregnancy history?

01

Any pregnant woman who is seeking prenatal care or assistance should fill out the Health Start Pregnancy History form. It helps healthcare providers assess the individual's medical background, identify potential risk factors or complications, and tailor their care accordingly. The form is especially important for women who are accessing prenatal care through the Health Start program or similar healthcare initiatives.

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