Prenatal Health Concerns Survey | Driscoll Health Plan

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.

* = required

Name:*

First Last

Birth date:*

Mobile number:*

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:

Hidden

PriorProblems

Hidden

HealthProbEsc

Hidden

SocialEsc

Hidden

FoodInsecurity

Hidden

LackTrans

Hidden

UtilitiesOff

Hurt

Hidden

Threat

Hidden

Spanish

SendEscalation