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)

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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?

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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

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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

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Time Spent

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