Test | Driscoll Health Plan

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Thanks for being patient! These questions will help us support you during your pregnancy.

Your information will be completely private and will not be shared or used for any other purpose and will remain within Driscoll Health Plan.

Questions marked with an asterisk (*) are required
Due date*
MM slash DD slash YYYY

(If you don’t know your exact due date, please use your best judgment to estimate as closely as possible.)
Have you picked a healthcare provider for your pregnancy?*
- Yes
- No (If you haven’t, we can help you with this process.)
That’s great! Have you had your first prenatal appointment, or is it scheduled?*
- Yes, I had my appointment
- My first prenatal appointment is scheduled
- My first prenatal appointment is not yet scheduled
Do you currently have, or ever had, complications with a pregnancy (pre-term birth, gestational diabetes, miscarriage, stillbirth, placenta previa, high blood pressure, etc.)?*
- Yes
- No
Have you ever given birth to a child with mental or physical challenges such as Down Syndrome, spina bifida, cleft palate, heart defect, etc.?*
- Yes
- No
- This is my first child
Have you ever had a child admitted to the NICU?*
- Yes
- No
- This is my first child
Do you have any of these health conditions now, or did you have them before you became pregnant?
(Select all that apply)

These health conditions can affect your health and the health of the baby. Make sure your pregnancy provider knows about all your health conditions and your medications.
- Diabetes
- Anxiety or Depression
- Epilepsy or seizures
- Heart disease (heart condition)
- High blood pressure
- Kidney problems
- Positive tuberculosis test at any time (even if you don’t have it now)
- Sexually transmitted infection (STI or STD) at any time (even if you don’t have it now)
- Sickle cell disease
Do you smoke, vape, or use tobacco?*
There’s no judgement here. The more you tell us, the better support we can give you. We promise we won’t share your answers with anyone.
- Yes, regularly
- Yes, occasionally
- Not while pregnant
- I did at one time but I have quit
- Never
Do you drink alcohol?*
There’s no judgement here. The more you tell us, the better support we can give you. We promise we won’t share your answers with anyone.
- Yes, regularly
- Yes, occasionally
- Not while pregnant
- I did at one time but I have quit
- Never
Do you use drugs?*
(for example, marijuana, cocaine, meth, heroine, opioids, ecstasy)

There’s no judgement here. The more you tell us, the better support we can give you. We promise we won’t share your answers with anyone.
- Yes, regularly
- Yes, occasionally
- Not while pregnant
- I did at one time but I have quit
- Never
How comfortable are you following your provider’s pregnancy care plan on your own?*
- Very comfortable
- Somewhat comfortable
- Uncomfortable
Do you ever feel like you may hurt yourself or others?*
If you feel this way, we can point you to resources that can help you. We promise we won’t share your answers with anyone.
- Yes, I do often
- Yes, occasionally
- Never
- I prefer not to say
Which of these Driscoll prenatal services are you aware of?
(select all that apply)
- Baby showers
- Nutrition counseling
- Transportation services
- Nurse Advice Line (available 24/7)
- SHIPT grocery delivery service for high-risk pregnant members
Which of these Driscoll postpartum services are you aware of?
(select all that apply)
- New mom home visit
- Parenting class
- Lactation consultation
- Child passenger safety class
- Nutrition counseling
- Transportation services
- Nurse Advice Line (available 24/7)
Terms & Conditions*
- I have read and agree to the Terms & Conditions for this program.
This text program is not meant to replace regular medical care provided by your doctor, but to enhance the care plan from your provider. Be sure to visit your provider regularly.
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