Prenatal Nutriation Assessment
State of California ? Health and Human Services Agency
California Department of Public Health
Prenatal Nutrition Assessment
Client ID:
ANTHROPROMETRIC
Weight Category:
Underweight
Single Weight gained during prior pregnancies:
Normal Twins pounds
Overweight N/A
Obese
BIOCHEMICAL
HGB:
HCT:
Fasting Blood Glucose:
Date of Consultation:
Other Labs:
CLINICAL Gravida: Blood pressure:
Para: Date:
Urine Analysis
Ketones:
/ Date:
Glucose: / Date:
Protein:
/ Date:
Abnormal lab value?
REFERRAL NEEDED? No Yes
Last pregnancy end-date: Abnormal blood pressure? No Yes
1. Are you experiencing any of the following discomforts? (mark all that apply)
No Yes
Nausea Vomiting Constipation
Dizziness Diarrhea Gas
Hemorrhoids Heartburn Other:
Leg Cramps Swollen Feet or Hands
2. Do any of these discomforts keep you from eating as you normally would? If yes, explain:
No Yes
3. Do any of the following apply to you? (mark all that apply)
Under 19 years of age
Currently breastfeeding another child
Anemia
Gastric Surgery Teeth, gums, or mouth problems
Diabetes:
Type 1
Type 2
Gestational
Currently pregnant with multiples Twins
Triplets or more
No Yes
Ever had a baby who weighed less than 5.5 pounds
No Yes
Ever had a baby who weighed more than 9 pounds
No Yes
Ever been told your unborn baby was not growing well
No Yes
Ever had an eating disorder (anorexia, bulimia, disordered eating)
No Yes
Ever had complications during a pregnancy
No Yes
Explain:
Other issues:
No Yes
CDPH 4472C (9/2022)
Page 1 of 4
DIETARY
4. Are you currently taking any of the following?
Item
Which one(s)?
Iron
Folic Acid
Prenatal vitamins
Other vitamins or minerals
Natural remedies or herbs
Liquid or powdered supplements
Laxatives
Prescription medication
Antacid
Over-the-counter medication
How much?
How often?
REFERRAL NEEDED?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
5. Are you allergic to any foods? Explain:
No Yes
6. Do you choose any of the following types of foods? (mark all that apply)
Low in sugar
Low in fat
Low in salt
Vegetarian
Gluten-free
For weight loss
For weight gain Other:
No Yes
7. Do you eat from the following food groups? (mark all that apply)
Eggs
Dairy
Poultry (fish)
Yes No
8. If yes to questions 6 and 7, did anyone tell you to make these food choices? Explain:
9. Do you avoid any foods?
No Yes
10. If yes to question 9, why do you avoid these foods?
Do not like
Allergy
Intolerance
Other:
11. Do you ever eat any of the following foods: (mark all that apply) Unpasteurized milk or cheese Shark, swordfish, king mackerel, or tilefish Raw or undercooked eggs, meats, shellfish, or fish Alfalfa/mung bean sprouts Deli meat
No Yes
12. Do you eat fish or shellfish from stores or restaurants more than twice per week? No Yes
13. Do you eat fish caught locally (not store-bought) more than once per week?
Page 2 of 4
No Yes
14. Do you eat or have you craved any of the following? (mark all that apply)
Clay or dirt
Laundry starch
Ice or freezer frost
Cornstarch
Plaster or paint chips
Other non-food item:
15. Who buys the food where you live?
Myself Other:
No Yes
16. Who cooks the meals where you live? Myself Other:
17. In the past year, did you worry about running out of food?
No Yes
18. In the past year, did you run out of food and not have money to buy more? No Yes
19. Do you receive WIC?
Yes No
20. Do you receive food stamps?
Yes No
21. Do you receive any free food services (food banks, pantries, or soup kitchens)? Yes No
22. Do you have the following items at home?
Oven
Electricity
Microwave
Stove
Refrigerator
Clean running water
23. Has your appetite been good since becoming pregnant?
Yes No Yes No
24. Have you had any changes in your eating habits since becoming pregnant? No Yes Explain:
25. Describe how you feel about the weight you have gained with this pregnancy:
26. Have you fasted or do you plan to fast during this pregnancy?
27. On an average day, do you spend over 2 hours watching television?
28. On an average day, are you physically active for at least 30 minutes?
29. Have you ever breastfed or tried to breastfeed? a. How long did you breastfeed? b. Did you breastfeed as long as you wanted? c. What was your experience like?
No Yes No Yes Yes No Yes No
Page 3 of 4
30. Is there anything that would prevent you from attempting to breastfeed? Explain:
No Yes
31. Who can you go to for breastfeeding help?
32. Have you ever smoked cigarettes or used tobacco? a. If yes, when did you last smoke cigarettes or use tobacco?
No Yes
b. If you smoke, how many packs of cigarettes do you smoke per day?
c. How interested are you in quitting smoking? 1
2
3
Not
interested
4
5
Very
interested
33. Have you ever drank alcohol (beer, wine, wine coolers, hard liquor)?
No Yes
a. If yes, when did you last drink alcohol?
b. How much alcohol do you drink and how often?
c. How interested are you in quitting drinking? 1
2
3
4
5
Not
Very
interested
interested
34. Have you ever used recreational drugs?
a. If yes, which drugs did you use ?
b. When did you last use drugs?
c. If you use drugs, how much do you use and how often?
d. How interested are you in quitting drugs? 1
2
3
Not
interested
No Yes
4
5
Very
interested
Assessor's Signature and Title
Date
Page 4 of 4
Time Spent
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