Pregnancy Notification Form

Member Information

Full Name

Date of Birth

Email Address

Cell Phone Number

Home Phone Number

Street Address

City

State

ZIP Code

Medicaid ID

Medicaid Managed Care Plan

Date of Last Menstrual Period (LMP)

Estimated Due Date

Is this your first pregnancy?

Yes No

Emergency Contact Name

Relationship

Emergency Contact Phone Number

Physician/Provider Information

OB Physician/Provider Name

Cell Phone Number

Physician/Provider NPI

Health History

Have you given birth in the last 12 months?

Yes No

Have you given birth in the last 6 months?

Yes No

Number of Full-Term Deliveries (> 37 weeks)

None 1 2 3 or more

Number of Preterm Deliveries (< 37 weeks)

None 1 2 3 or more

Number of Miscarriages/Abortions

None 1 2 3 or more

Number of Stillbirths

None 1 2 3 or more

Have you had a previous C-section?

Yes No

How many C-sections have you had?

1 2 3 or more

Please select all applicable high-risk factors for you:

Do you smoke or vape?

Yes No

Second-hand smoke exposure?

Yes No

Do you use illicit drugs?

Yes No

Are you on a prescribed opioid?

Yes No

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Pregnancy Notification Form

Pregnancy Notification Form

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