First Trimester Assessment

First Trimester Assessment
A four-page initial pregnancy assessment for the first home visit of a maternal health program. Captures patient identification, demographics and obstetric history (age, pre-pregnancy weight, height, weight, BMI, gravida, para, EDC), vital signs, medical and mental health history, medications, allergies, and dental care, then works through pregnancy planning, symptoms and prenatal care, PCP notification, social support and living environment, substance use and exposure to violence, transportation and work plans, and a nutrition and feeding plan including breastfeeding intentions. Closes with the next prenatal visit, a psychosocial assessment, an individual care plan, smoking cessation counseling, a nine-item referral checklist (pediatrician, WIC, domestic violence program, food stamps, car seat program, housing, prenatal vitamins, dental, drug abuse program), health education topics, and a narrative page. Delivered as a fillable PDF for electronic charting and a print-ready paper version. Branded and ready to customize with your agency logo.