Olympic Educational Service District 114

105 National Avenue North, Bremerton, Washington 98312

(360) 478-6887  1-800-201-1300  FAX (360) 405-5808

PRENATAL WELLNESS ASSESSMENT

Date Completed: Click or tap to enter a date.

Mother’s Name: Click or tap here to enter text. Due Date: Click or tap to enter a date.

Medical Insurance: Click or tap here to enter text. Primary Care Provider: Click or tap here to enter text.

Date of Last Prenatal Exam: Click or tap to enter a date. Date of Next Scheduled Prenatal Exam: Click or tap to enter a date.

Has Your Prenatal Provider Stated this is a High-Risk Pregnancy? Choose an item.

Other Services/Specialists/Public Health Nurse: Click or tap here to enter text.

Dental Insurance: Click or tap here to enter text. Dental Provider: Click or tap here to enter text.

Date of Last Dental Exam: Click or tap to enter a date. Up-To-Date on Immunizations? Choose an item.

What are your strengths as a parent? Click or tap here to enter text.

What are you doing to prepare for your baby’s birth? Click or tap here to enter text.

What are you looking forward to the most with the birth of your baby? Click or tap here to enter text.

Do you have any health concerns with your pregnancy? Click or tap here to enter text.

Who is your support system? Click or tap here to enter text.

Would you or anyone in your family like information about substance abuse/treatment (tobacco, alcohol, drugs)? Choose an item.

Are there any foods you cannot eat for medical, cultural, or religious reasons? Choose an item.

Tell me about mealtimes. What are your favorite foods? What makes mealtime enjoyable and what makes it challenging? Click or tap here to enter text.

Do you have any questions or concerns about your nutrition? Click or tap here to enter text.