Pregnancy Testing

PREGNANCY TEST VISIT
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Marital Status*

MarriedIn Relationship
Address*

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
County of Residence*
I.e., Platte County, Clay County, Jackson County, etc.
Race*
Ethnicity*
Phone Number*
Social Security Number*
If none put "none"
Insurance Plan Name and ID #*
If none put "none"
Significant Other's Name*
Significant Other's Date of Birth*

MonthDayYear
Date
Significant Other's Race*
Do you have children?*

YesNo
Child One's Name and Date of Birth
Do you have any other children?

YesNo
Child Two's Name and Date of Birth
Do you have any other children?

YesNo
Child Three's Name and Date of Birth
Do you have any other children?

YesNo
Child Four's Name and Date of Birth
Do you have any other children?

YesNo
Child Five's Name and Date of Birth
Do you have any other children?

YesNo
Child Six's Name and Date of Birth
Reason for Today's Visit
Have you taken a home pregnancy test?*

YesNo
If yes, did it show that you are pregnant?

YesNo
When was the FIRST DAY of your last period?*

MonthDayYear
Date
Was this period regular and on time?*

YesNo
How often do you get your period?*
How many days do you bleed?*
Do you have any of the following symptoms? (Check all that apply)*

NauseaFrequent UrinationBloody Vaginal DischargeIncreased Vaginal DischargeVomitingUnusually TiredLower Abdominal Pain/CrampsEnlarged or Painful Breasts
Date Bleeding Started

MonthDayYear
Date
Currently bleeding?

YesNo
How would you describe the bleeding?

SpottingModerateHeavy
Are Pain/Cramps Severe?

YesNo
Are you currently using anything to prevent pregnancy? (Check all that apply)*

CondomsBirth Control PillDepo Provera (shot)Birth Control ImplantIUDDiaphragmVaginal Contraceptive Foam/Film/SuppositoryNone of the above
Last Date Pill Taken?

MonthDayYear
Date
Last Date Shot Taken

MonthDayYear
Date
Date Implant Inserted

MonthDayYear
Date
Date Inserted

MonthDayYear
Date
How often do you use condoms?

SometimesAlways
Are you currently trying to get pregnant?*

YesNo
Number of pregnancies*
Number of miscarriages*
Number of abortions*
Number of births*
Number of children*
The Platte County Health Department offers a variety of services for you and your family. Services offered for Platte County mothers include FREE programs that provide you with support, education and community referrals based on the needs of your family. A representative from PCHD will be contacting you to provide you with more information. I hereby give my permission to share this information with the Platte County Health Department and other agencies to follow up with the information provided.
Client Signature*

Clear
The Patient Health Questionnaire (PHQ-9)
Name*
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things*

Not at allSeveral daysMore than half the daysNearly every day
Feeling down, depressed, or hopeless*

Not at allSeveral daysMore than half the daysNearly every day
Trouble falling asleep, staying asleep, or sleeping too much*

Not at allSeveral daysMore than half the daysNearly every day
Feeling tired or having little energy*

Not at allSeveral daysMore than half the daysNearly every day
Poor appetite or overeating*

Not at allSeveral daysMore than half the daysNearly every day
Feeling bad about yourself-or that you're a failure or have let yourself or your family down*

Not at allSeveral daysMore than half the daysNearly every day
Trouble concentrating on things, such as reading the newspaper or watching television*

Not at allSeveral daysMore than half the daysNearly every day
Moving or speaking so slowly that other people could have noticed. Or, the opposite-being so fidgety or restless that you have been moving around a lot more than usual*

Not at allSeveral daysMore than half the daysNearly every day
Thoughts that you would be better off dead or of hurting yourself in some way*

Not at allSeveral daysMore than half the daysNearly every day
If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult
Should be Empty:

PREGNANCY TEST VISIT

Reason for Today's Visit

The Patient Health Questionnaire (PHQ-9)