Members

     
 
 
 

Little Steps

Pregnancy Planning Health Assessment
Please complete this confidential Pregnancy Planning Health Assessment to help us consider your unique healthcare needs. A health coach will call you to discuss what you can do now to significantly increase your chances of having a healthy baby later on.

If you have any questions, please contact us at (401) 459-2273 or 1-800-637-3718 ext. 2273.

Name:  
 
Date of Birth:  
 
Member ID:  
 
 
Address:  
 
  
 
  
 
  
 
City:  
 
State:  
 
Zip:  
 
Phone Number:  
 
 Alternate Phone Number:  
 
 Best day to call (Mon-Fri):  
 
 Best time(s) to call:  
 
   
Check any of the boxes below if they apply.  
   
Will this be your first pregnancy?  
 
Are you taking a multivitamin  
w/folic acid?  
 
Do you have diabetes, high blood   pressure, asthma, or other health   conditions or concerns?  
 
If yes, please explain:  
 
Do you smoke?  
 
Do you exercise?