State of Illinois

Illinois Department of Healthcare and Family Services

PRECONCEPTION RISK ASSESSMENT TOOL (PAGE 1 OF 2)

All questions contained in this checklist are strictly confidential and will become part of your medical record.
Name

DOB:

(Last, First, MI.):

Marital status:

Single

Partnered

Married

Separated

Previous or referring
doctor:

Intent of Pregnancy:

Divorced

Widowed

Date of last physical exam:

Are you planning to get pregnant in the next 6 months? Yes No In the next 12 months? Yes No
Does your partner support your pregnancy plan? Yes No
Are you using any birth control methods? Yes No
If yes, what type? Oral (pills) Depo (shot) Patch Nuva Ring IUD/IUS Condoms
Other _______________________
Have you ever had sex? Yes No If yes, when was the last time? ____________________
Healthcare Provider Notes:

Medical History

Do you have a history of?

Diabetes Seizures Thyroid Disease

Asthma Anemia Hepatitis Lupus Kidney disease
Hemophilia
High Blood Pressure Sickle Cell Disease Active TB Cancer Type______________

Does your partner have a

history of? (Check all that

Sickle Cell Disease

apply)

Healthcare Provider Notes:

Immunization History

Measles, Mumps, Rubella (MMR)

HIV/AIDS

Hepatitis

Hepatitis B

Chickenpox

Tetanus/Diphtheria/Pertussis (Tdap)

Healthcare Provider Notes:

Genetic History
Do you or your partner
have a family history of?
(Check all that apply)

Tay-Sachs

Yes No Dont Know

Sickle Cell Disease

Yes No Dont Know

Birth Defects

Yes No Dont Know

Muscular Dystrophy

Yes No Dont Know

Downs Syndrome

Yes No Dont Know

Yes No Dont Know

Cystic Fibrosis

Yes No Dont Know

Hemophillia

Yes No Dont Know

Niemann-Pick Disease Yes No Dont Know

Trisomy 18

Yes No Dont Know

Other _________________________________

Gauchers Disease Yes No Dont Know

PKU

Healthcare Provider Notes:

Reproductive History
A

When was your last period? ___/___/______

How many sanitary products do you use each cycle? ____

Do you have a period every month? Yes No

Have you had an abnormal pap test? Yes No

Do you have a history/or were you treated for the following? (check all that apply)
Preeclampsia/eclampsia

Gestational diabetes

Genital Herpes Gonorrhea HIV/AIDS Genital Warts Chlamydia Syphilis Trichomonas HPV
Have you ever been pregnant? Yes No
Have any of your babies died at birth or during their first year of birth? Yes No
Healthcare Provider Notes:

Reproductive History
B

LEEP: Yes No

Cone Biopsy: Yes No

Surgeries on: Uterus

Ovaries

Birth Outcomes: G__ P__ __ __ __

Tubes

Date of the last pregnancy outcome: ___/___/______

Breast

Cervix

Prior ectopic
pregnancy

Prior
fetal deaths

Congenital
anomalies

Prior preterm birth(s) Birth weight _______, _______, _______, ________.

Healthcare Provider Notes:

HFS 27 (N-1-12)

HFS/Bureau of Maternal and Child Health Promotion

PRECONCEPTION RISK ASSESSMENT TOOL (PAGE 2 OF 2)

Medication and
Supplements

Diet and Exercise

Are you taking any of the following? Folic acid Multivitamins Calcium Iron
Diet pills Herbal remedies Over the counter medication
Are you taking any medications? Yes No
If yes list: _________________________________________________________________________________
Are you allergic to any medication?
If yes list: _________________________________________________________________________________
Healthcare Provider Notes:

Are you at a healthy weight? Yes No

Are you: Overweight or Underweight
Are you on a special diet? Yes No Check all that apply: Diabetic Low Salt Other ____________
Do you eat? Raw meat Raw fish

Do you eat fruits and vegetables every day? Yes No

Do you drink milk or juice with calcium? Yes No

Do you exercise? Yes No

Do you have problems with your teeth or gums? Yes No

Have you seen a dentist in the past year? Yes No
Healthcare Provider Notes:
Lifestyle

Do you smoke cigarettes or use other tobacco products? Yes No How often? ______ How much? _______
Are you exposed to second hand smoke? Yes No
Do you drink alcohol? Yes No

How often? ________________

How much? ________________

Do you or have you used drugs? Cocaine/crack Heroin Ecstasy Marijuana Methamphetamines
Methadone Other ________________________
Are you in a rehab program? Yes No
Healthcare Provider Notes:

Environmental
Health

Do you have any pets? Yes No If yes, check all that apply: Cats Rodents Exotic Animals
Have you had contact with: Contaminated soil Cat litter
Do you or your partner have to wear protective coverings at the job? Yes No
Do you or your partner work with? Pesticides Cleaning fluids Chemicals Paint
Healthcare Provider Notes:

Emotional Support

Do you have emotional support at home? Yes No

Is help available from relatives or friends? Yes No

Are you worried about being homeless this year? Yes No

Are you in a stable relationship? Yes No
Do you feel safe at home? Yes No

Are you physically threatened? Yes No

Do you feel good about yourself? Yes No

Have the following been diagnosed with depression? You Your family Your partner
Healthcare Provider Notes:

Baby Preparations

If you are planning a pregnancy: Do you have a place for the baby to stay? Yes No
Do you need WIC? Yes No

Do you plan to breast feed? Yes No

Healthcare Provider Notes:

Demographics

Are you Hispanic or Latino? Yes No

What is your race? (check all that apply):
African American White Asian Indian Japanese Korean
Chinese Samoan Filipino Hmong Other Asian Native Hawaiian Native American/Alaska Native
Guamanian or Chamorro Other Pacific Islander
What is the highest grade of education you completed? ____________
Do you have a GED? Yes No
Do you or your partner have maternity insurance? Yes No
Do you have employer maternity leave? Yes No
Healthcare Provider Notes:

HFS 27 (N-1-12)

HFS/Bureau of Maternal and Child Health Promotion

The Foundation for Accessing Preconception Care

The U.S. Centers for Disease Control and Prevention defines preconception care as interventions that aim to
identify and modify biomedical, behavioral, and social risks to a womans health or pregnancy outcome through
prevention and management. The most fundamental elements of preconception care include screening for
medical, behavioral and social risk factors that can impact a healthy pregnancy, and then intervening through
appropriate educational and community resources to deliver effective treatment and prevention plans.
Preconception care helps women think about how their behaviors, lifestyle choices and medical conditions may
affect their ability to have a healthy pregnancy. Preconception evaluations allow healthcare providers to assess
possible risks to pregnancy, discuss pregnancy planning, and discontinue potentially teratogenic medications
prior to becoming pregnant.
In Illinois, the Department of Healthcare and Family Services has supported a myriad of preconception care
initiatives. Through partnership with its quality improvement organization eQHealth Solutions, a practical
preconception tool was developed for the provider community. This risk assessment tool comprises the key
tenets of preconception health for easy incorporation into a standard medical record. The tool includes
categories related to lifestyle, reproductive, medical and genetic history, emotional support, as well as
environmental and occupational risks.
As an adjunct to a womans medical history, the preconception risk assessment begins with questions related to
pregnancy intention. As learned by eQHealths physician panels and the Michael Reese Health Trust Peer
review, an essential component of preconception care is the consistent question of pregnancy intent by
healthcare providers. Since women often seek care from multiple providers, it is critical that each visit be viewed
as an opportunity to discuss pre-conception health.
The following guidance is to be used in conjunction with the preconception risk assessment tool:

Pregnancy Intention Screen at Every Visit

Tool Section
Pregnancy Intention

Last menstrual period

Yes

No or Unsure

Check UCG if negative

o proceed with preconception check list
o discuss health benefits of pregnancy planning
UCG positive
o schedule prenatal care
o prescribe prenatal vitamins
o discuss involvement of partner

Last menstrual period- if abnormal

HFS 27 (N-1-12)

Recommendations

Check UCG
Unprotected intercourse in the last month if yes counsel for STI
prevention and birth control options
Discuss birth control options
Screen for compliance
Discuss side effects
Discuss health benefits of pregnancy planning and spacing (18-24 mos)
Encourage annual health assessments

HFS/Bureau of Maternal and Child Health Promotion

Preconception Risk Assessment Tool Reference

Tool Section
Medical History
Infectious Diseases
Immunizations

Genetic Risk Factors

Reproductive History

Sexually Transmitted
Infections (STI)
Medications/
Supplements

Weight assessment

Lifestyle

Environmental
Health
Emotional Support

HFS 27 (N-1-12)

Recommendations

Screen for diabetes, thyroid disease, hypertension, seizure disorders and asthma.
Treatment and control of identified conditions. Counsel on fetal effects with
appropriate specialty referral.
Screen for HIV, Hepatitis B surface antigen, Hepatitis C, Tuberculosis
Check Immunization status for:
MMR vaccination recommended if non-pregnant, not vaccinated or non
immune. Since it is a live vaccine, women should be counseled not to become
pregnant for 3 months after receiving the MMR vaccination.
Hepatitis B vaccination recommended for high-risk.
If Varicella is discovered during pregnancy, the series be initiated immediately
after delivery (or termination of pregnancy) with a second vaccination in the
series at the 6-week postpartum visit.
Tdap immunization status unknown women should receive one dose.
3-generation family history for both members of the couple.
Screen for ethnically related genetic disorders
Congenital malformations
Developmental delay/mental retardation
If positive refer for genetic counseling.
Screen for preterm or low birth weight infants screen for underlying causes.
Miscarriages - structural evaluation of the uterus and work-up to determine the
underlying etiology.
C-section - counsel to wait at least 18 months before the next pregnancy.
LEEP or CONE biopsy counsel regarding increased risk of PTL.
Screen for Chlamydia, GC, Syphilis
Treat all active STIs (Including Herpes)
Prevention counseling
Folic Acid - 400 g daily
Calcium - 1000 mg/day for pregnant and lactating women > 19 years old
1300 mg/day for pregnant and lactating women < 19 years old.
Screen for iron deficiency
Screen for psychotropic medications
Anti-depression patient chart www.hfs.illinois.gov/mch/medchart.html
Screen for medications contraindicated to a pregnancy
IL Teratogen Information Service 1-800-252-4847 www.fetal-exposure.org
Calculate annual BMI
Counsel if BMI < 19.8 or > 26 due to risks to fertility
Refer to treatment programs for eating disorders
Suggest well-balanced diet of fruits and vegetables
Screen for alcohol consumption counsel on fetal effects of alcohol.
Screen for tobacco use counsel on fetal effects, refer chronic smokers to QUIT
line or other formal smoking cessation programs.
Screen for illicit drugs - counsel on fetal effects, refer to treatment programs.
Screen for methadone usage and enrollment in outpatient drug rehabilitation.
Rural residents - screen water quality, bacteria, pesticides and toxic exposure.
Screen for exposure to chemicals. Refer to occupational medicine specialist if
necessary.
Counsel on effects of exposure to pet feces
Screen for depression
If present, mental health referral
Screen for domestic and partner violence
Refer to Crisis Centers

HFS/Bureau of Maternal and Child Health Promotion