Health Risk Assessment

Pregnant HRAGomoWPAdmin2023-11-20T17:27:19+00:00

Welcome to Driscoll Health Plan. Our records indicate that you are pregnant. We want to hear from you so that we can better serve you throughout your pregnancy and delivery. Our case managers are here to give you good advice and help to make sure you have the best chance of having a healthy baby. Please answer these important Health Risk Assessment questions so we can provide as much assistance as possible.

* = required
Member Name*
First Last
If Child: Parent/Guardian Name
First Last
Member ID or SSN*
Member Date of Birth*
MM slash DD slash YYYY
Member Age*
Member Address*
Street Address Address Line 2 City State ZIP Code
PCP Name*
Our records indicate that you are pregnant. Is this correct?*
- Yes
- No
When is your baby due?*
MM slash DD slash YYYY
Who is your OB/GYN doctor?*
Have you seen your OB/GYN doctor?*
- Yes
- No
When is your next appointment to see your doctor?*
MM slash DD slash YYYY
Is this your first pregnancy?*
- Yes
- No
How many live births?*
How many children do you have?*
Age for Each Child:

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Were there any problems with your pregnancies?*
- Yes
- No
Please list the problems:
Do you have swollen or bleeding gums, a toothache, problems eating or chewing food, or other problems in your mouth?*
- Yes
- No
Do you have any of the following health problems?
Please select all that apply.
- Diabetes
- Depression
- Anxiety
- Heart Disease
- Hypertension
- Substance Abuse
- Kidney Disease
Thank you for the corrected information. We will update our records.
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University of Michigan, 12/13 – Clinical Alignment and Performance Excellence Prenatal Guidelines
Retrieved from http://www.med.umich.edu/1info/FHP/practiceguides/newpnc/PNC.pdf
The Accountable Health Communities Health-Related Social Needs Screening Tool
https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf

Health Risk Assessment

Thank you for the corrected information. We will update our records.