Prenatal Chat Survey | Driscoll Health Plan

Please answer a few quick questions so we can get to know you and your baby’s needs.

* = required

Name:*

First Last

Birth date:*

Mobile number:*

Medicaid ID:*

Hidden

Medicaid ID:*

Do you know your due date?*

Yes
No

What is your due date?*

How far along are you in your pregnancy?*

Do you have any health concerns about you or your baby?*

Yes
No

These questions will let us know how we can help you. You will also receive a $20 gift card for completing this section. One of our nurses will contact you for further assistance.

If this is not your first pregnancy, did you have problems with your other pregnancies?*

Yes
No
Not applicable

Please list the problems:*

Do you have any of the following health problems?

Diabetes
Depression
Heart Disease
Kidney Disease

Do you smoke?*

Yes
No

Would you like our Social Workers to assist you with any needs?*

Yes
No

Please let us know what we can help you with.*

Living Situation

What is your living situation today?*

Rent
Own
Live with a relative/friend

Where you live, do you have problems such as pests, mold, leaks, etc.?*

Yes
No

Please list the problems:*

Food

In the past 12 months, you worried that your food would run out before you got money to buy more.*

Often true
Sometimes true
Never true

In the past 12 months, the food you bought didn’t last and you didn’t have money to get more.*

Often true
Sometimes true
Never true

Transportation

In the past 12 months, has lack of reliable transportation kept you from a medical appointment, meetings, work or from getting things needed for daily living?*

Yes
No

Please list the problems:*

Utilities

In the past 12 months, has the electric, gas, or water company threatened to shut off services in your home?*

Yes
No
Already Shut Off

Safety

How often does anyone, including family and friends, physically hurt you?*

How often does anyone, including family and friends, insult or talk down to you?*

How often does anyone, including family and friends, threaten you with harm?*

How often does anyone, including family and friends, scream or curse at you?*

Have you had an appointment with your OB yet?*

Yes
No

Do you have any other children on Driscoll Health Plan?*

Yes
No

Why did you choose Driscoll Health Plan*

Select all that apply

Because of the extra benefits (Value Added Services)
Because my doctor(s) take Driscoll Health Plan
Because my kids have Driscoll Health Plan
Because friends/family recommended Driscoll Health Plan
Because I saw an advertisement in the community
Other

"Other" is selected, please specify:*

What’s your preferred method of contact?*

Text
Email
Phone call

What is your email address?*

Additional Comments:

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SendEscalation

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PriorProblems

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HealthProbEsc

Hidden

SocialEsc

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FoodInsecurity

Hidden

LackTrans

Hidden

UtilitiesOff

Hidden

Hurt

Hidden

Threat

Hidden

HealthConcerns

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Spanish