SECTIONS / B1. Demographic Intake / B2.
Pregnancy History / B3. Preconception / B4.
Prenatal / B5. Postpartum / B6. Interconception/Parenting / Date Changed
Previous pregnancy outcomes
addition to staff instructions and table / Q3 / 12/14/16
Reproductive Life Planning
Follow up Box – minor edits and formatting / After Q 43.1 / After Q 51.1 / After Q 15.1 / After Q 18.1 / 12/14/16
Social Determinants of Health
List of Social Services –align responses for “Other” selection in table / Q9 / Q20 / Q24 / Q27 / 12/14/16
Maternal Health/Health History
Add “Iron deficiency anemia” to list of conditions – after “High Blood Pressure” / Q22 / Q29.1 / Q41.1 / 12/14/16
Maternal Health/Health History
STDs- add / align responses for “Other” selection in table / Q28 / Q34 / Q48 / 12/14/16
Maternal Health/Health History
Infectious diseases - add / align responses for “Other” selection in table / Q35 / Q49 / 12/14/16
Medical Home Questions
Modified skip pattern instructions / Q14 & 15 / Q9 & 10 / Q 33& 34 / 12/14/17
Maternal Health Section
Modified skip pattern instructions / Q40 – at the end under “other” / 12/14/17
Reproductive Life Planning
Birth control follow up – added field for date of service / Follow up box after Q43.1 / Follow up box after Q51 / Follow up box after Q15.1 / Follow up box after Q15.1 / 1/26/17
Maternal Health/Health History
Added response choice: “Not taking any medications” / Q32 / Q44 / 1/26/17
Guns Safety Section
Added response option “don’t’ know” / Q44 / 1/26/17
Stress and discrimination
Changed instructions for following up based on frequency of response from “month” to “year” / Q38 / 1/26/17
Formatting
Change “Date of Administration” to “Date of Initiation” and “Date of Completion” / Top of Form / Top of Form / Top of Form / Top of Form / Top of Form / 3/2/17
Pregnancy History
Ask for history of “five MOST RECENT” pregnancies in instructions include in instruction / Q3 / 3/2/17
Maternal Health/Health History
Insert generic name for Accutane in list of medications (isotretinoin). / Q24 / Q31 / Q43.1 / 3/2/17
Substance use
Add “including opioids, diet pills” In Prescription Drugs for Non-Medical Reasons, and remove “marijuana and diet pills” from Illegal Drugs sections. / Q33 / Q39 / Q41 / Q52 / 3/2/17
Child Health Status
Change “times” to “days” in question and in table / Q3 / 3/2/17
Child Insurance / Access to Care / Medical Home
Add responses: “Don’t know”, “Declined to answer” / Q11.1 / Q13.1 / 3/2/17
Medical Home/Access to Care/Health Insurance
Add response: “Declined to answer” / Q33 / 3/2/17
Pregnancy History
Insert instruction: “Ask Q 9 only if participant has living children”. / Q9 / 3/2/17
Social Determinants of Health
Add instructions:
STAFF: If zip code has changed, update address and contact information (questions 2 & 3) on Demographic Intake Tool. / Q6 / Q17 / Q21 / Q24 / 3/2/17
Social Determinants of Health
In list of Services Question:
Delete “Do not need” column / Q9 / Q20 / Q24 / Q27 / 3/2/17
Maternal Health/Health History
In Chronic Disease section: change Iron Deficiency Anemia to Iron Deficient Anemia / Q29 & 29.1 / Q41 & 41.1 / 3/2/17
Substance use
After substance use question in Follow-up Box insert specific follow-up guidance:
If participant answers “Yes” to 1 or more days of heavy drinking [for women, 4 or more drinks per day], complete further assessment using an evidence-based tool such as the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C).
If participant answers “Yes” to any use of illegal or prescription drug use for non-medical reasons, complete further assessment using an evidence-based tool such as the NIDA-Modified ASSIST or the DAST-10 Questionnaire. / Q33 / Q41 / Q52 / 3/2/17
Substance use
After substance use question in Follow-up Box Insert specific follow-up guidance:
For prenatal women with any alcohol use, complete further assessment using an evidence-based tools such as the TWEAK, T-ACE, or 4 Ps
For any use of illegal or prescription drug use for non-medical reasons, complete an evidence-based tool such as the NIDA-Modified ASSIST or DAST-10 Questionnaire. / Q39 / 3/2/17
Reproductive Life Planning
Change to:Would you like to become pregnant in the next “year”? / Q42.2 / Q14.2 / Q17.2 / 3/2/17
Maternal Health
Insert “youngest”
Did you have a postpartum checkup after your youngest child was born? / Q40 / 3/2/17
Introduction
Insert “annually”: This tool should be completed annually for women in the preconception period.
And add: “Only read the responses to the participant if the instructions for any question tell you to do so.” / Insert into intro / 3/2/17
Introduction
Insert “as soon as possible”: This tool should be completed as soon as possible for women in prenatal period. / Insert into intro / 3/2/17
Introduction
Add “postpartum” The postpartum phase refers to the time period from birth to six months after her baby is born.
And Add: For postpartum participants who are also pregnant, ask only the following questions about your last pregnancy, and about each baby younger than 6 months old:
•1 -13
•33, 33.1 & 33.2,
•42, 42.1,
• 50 & 50.1
•AND Complete the Prenatal Screening Tool / Insert into intro / 3/2/17
Introduction
For participants with a child/children 6 – 24 months old who are also pregnant, ask only the following questions:
- 1-16
- 36
- 40-40.1
- 59-59.1
- And complete the Prenatal Screening Tool
Parents or caregivers who are not enrolled participants should answer questions:
- 1-15
- 59-59.1
Demographic Tool
Add “decline to answer” for emergency contact on demographic tool / Q4 / 3/2/17
Demographic Tool
Add “Don’t Know” and “Declined to Answer” as responses / Q6 & Q7 / 3/2/17
Social Determinants of Health
Change response: “Children age 18 and younger” to “Children age 17 and younger” / Q4 / Q15 / Q19 / Q22 / 3/2/17
Maternal Health/Health History
Does your provider know all the medications that you are taking?
Add “not taking any medication” as a choice / Q32
Removed highlight / 3/2/17
Social Support
Change skip pattern instructions from “Go to question 49.1” to “Go to Question 50.1” / Q50 / 3/2/17
Pregnancy Outcomes
Add instructions: STAFF: Please read the responses out loud to participant and select all that apply. / Q 5.1 / 3/2/17
Maternal Health/Health History Section
Remove Q 43 “Are you taking any prescription medications?” and responses / Q43 and change 43.1 to 43 / 3/2/17
Pregnancy Status
Number of times pregnant:
Insert instructions: STAFF: Do not include current pregnancy if participant is pregnant. / Q2 / 3/2/17
Introduction
Change sentence:
“When there is more than one baby born at a single birth (twins, triplets, etc.), the mother…” to “When there is more than one childbetween the ages of 6 and 24 months old, the caregiver should answer about each child.
AND
Change “For participants with children only older than 24 months old, start at question 17.”
To:
”For participants who are not currently pregnant, with children only older than 24 months old, start at question 17.” / Intro / 5/12/17
Social Determinants of health
Modified skip pattern instructions
Response “Declined to answer “ change skip pattern from “(Go to question 7)” to “(Go to question 27)” / Q26 / 5/12/17
Introduction
Add:
Parents or caregivers who are not enrolled participants should answer questions:
- 1.1 – 13
- 50.- 50.1
“When there is more than one baby born at a single birth (twins, triplets, etc.), the mother should answer about each child.”
to
”When there is more than one baby between younger than 6 months old, the caregiver should answer about each baby” / Intro / 5/12/17
Pregnancy Outcomes
Change sentence:
“Please tell me the outcome of your pregnancy.”
To
“Please tell me the outcome of your most recentpregnancy.” / Q1 / 5/12/17
Introduction
Add:
If caregiver is a participant, she should complete all questions on the Pregnancy History tool.
If participant is a baby or child, and caregiver is not the mother of the baby/child and is enrolling as a participant, enter baby or child birth information on Pregnancy History tool (Question #3). / Intro / 5/12/17
Instructions
Change
“ STAFF: If participant has had any live births, continue to question 4. If participant has had only miscarriage, ectopic or tubal pregnancies, or abortion (and no live births) this TOOL IS COMPLETE….
To insert sentence:
“STAFF: If participant has had any live births, continue to question 4. if the participant has had no live births but a past stillbirth/fetal death, please ask questions 5 and 5.1 only. If participant has had only miscarriage, ectopic or tubal pregnancies, or abortion (and no live births) this tool is complete…” / After Q3 / 5/12/17
Instructions
Change:
If caregiver is a participant, she should complete all questions on the Pregnancy History tool.
If participant is a baby or child, and caregiver is not the mother of the baby/child and is enrolling as a participant, enter baby or child birth information on Pregnancy History tool (Question #3).
To insert sentences:
Participants should complete this tool, and include information in Question 3 birth information for any baby or child to which she is a caretaker.
If the caretaker is not a participant, complete only question 3, entering the baby or child birth information in the table as a Live Birth. / Intro / 6/1/17