DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN
Division of Medicaid Services Wis. Admin. Code § DHS 107.34(1)(c)
F-01105 (07/2024)
FORWARDHEALTH
PRENATAL CARE COORDINATION PREGNANCY QUESTIONNAIRE
INSTRUCTIONS: Type or print clearly. Before completing this form, read the Prenatal Care Coordination Pregnancy
Questionnaire Instructions, F-01105A. Providers may refer to the Forms page of the ForwardHealth Portal at
www.forwardhealth.wi.gov/WIPortal/Subsystem/Publications/ForwardHealthCommunications.aspx?panel=Forms for the
completion instructions.
The use of this form is required. Providers are required to use this form to determine member eligibility for the prenatal
care coordination (PNCC) benefit. A member is eligible for PNCC services if they either 1) have four or more identified risk
factors below or 2) are less than 18 years old (regardless of the number of risk factors identified). Questions that indicate
risk factors are marked with an asterisk (*). If a risk factor applies, providers should check the box next to the asterisk. For
eligible members, the questionnaire will be used to inform the care plan.
SECTION I – GENERAL INFORMATION
1. Name – Member (Last, First, Middle Initial)
2. Address – Member (Street, City, State, Zip Code)
3. County 4. Primary Phone Number – Member
5. Email – Member
6. What is the best way to contact the member? When is the best time to contact the member?
7. Member ID Number
8. Date of Birth – Member * 9. Age – Member
* 10. What ethnicity does the member identify as? * 11. What race does the member identify as? (Check
all that apply.)
Hispanic
American Indian / Alaska Native
Non-Hispanic
Asian
Black / African American
Hawaiian / Pacific Islander
White
Other:
* 12. Education (Check highest grade completed.) * 13. Marital Status
Did not complete high school Married
Completed high school (grades 1-12) or Not married
equivalent (For example, GED diploma)
Received college degree (Associate’s,
Bachelor’s, or Master’s Degree)
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F-01105 (07/2024)
14. Name – Emergency Contact 15. Phone number – Emergency Contact
SECTION II – CURRENT PREGNANCY
1. Is the member pregnant with more than one baby (for 2. When is the member’s due date?
example, twins or triplets)?
Yes No
* 3. When was the member’s first medical appointment related to their current pregnancy (for example, a primary
care or OB/GYN appointment)?
(Month/Year)
The member has not had an appointment yet but has one scheduled on:
(MM/DD/CCYY).
The member has not had an appointment and does not have one scheduled.
* 4. Is the member receiving nutrition services from the * 5. Record the member’s height and weight.
Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC)? Member’s weight before pregnancy:
Yes No Member’s current weight:
Member’s height:
6. What is going well in the member’s pregnancy so far (For example, medically, emotionally, or socially)?
7. What are the member’s goals for this pregnancy (For example, nutritional goals, habit goals, or emotional goals)?
* 8. If the member could change the timing of this 9. Is the member planning to breastfeed their baby?
pregnancy, would it be earlier, later, or no change,
or would the member prefer to not be pregnant at
Yes
all? No
Earlier (For example, member has been trying Undecided
to get pregnant for a long time)
Later
No change
No pregnancy at all
10. What does the member know about breastfeeding? What are their thoughts about or experiences with
breastfeeding?
11. Has the member had any bleeding or cramping during this pregnancy? Yes No
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F-01105 (07/2024)
SECTION III – PREGNANCY HISTORY (If this is the member’s first pregnancy, skip to Section IV.)
1. Has the member ever been pregnant before? 2. How many children does the member currently have in
Yes No their care, including children they have given birth to or
adopted?
3. How many living children has the member given birth 4. How many of the member’s births were full-term live
to? births (not premature delivery)?
* 5. How many of the member’s births were more than * 6. How many times has the member had a
three weeks early (premature delivery)? miscarriage or lost a pregnancy at 20 weeks or
later?
* 7. How many times has the member had a * 8. How many babies has the member given birth to
miscarriage or lost a pregnancy before 20 weeks that weighed 5.5 pounds or less at birth?
(including planned and unplanned end of
pregnancy)?
9. How many babies has the member given birth to that * 10. How long has it been since the member’s last
weighed more than 9 pounds at birth? pregnancy? Enter the date their last pregnancy
ended.
11. What was the outcome of the member’s last pregnancy?
Live Birth
Miscarriage or Other Loss
SECTION IV – HEALTH INFORMATION
Health and Dental Conditions
1. Does the member have a primary care physician (PCP)? Yes No
If yes, enter the provider’s name and contact information below (if available).
* 2. Check all conditions that the member has or has ever had that have required ongoing medical care. Check all
that apply.
Asthma High Blood Pressure / Hypertension
Chlamydia, Gonorrhea, Syphilis, or Genital Seizures or Epilepsy
Herpes
Urinary Tract Infection
Diabetes (Type ____)
Other Illness, Infection, or Condition Requiring
Ongoing Medical Care
3. Has the member been screened for sexually transmitted infections (STIs),
including HIV and syphilis, during this pregnancy? Yes No
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F-01105 (07/2024)
* 4. How many times has the member been to a dentist or dental clinic in the last two years?
Does the member have painful or loose teeth, bleeding gums, or a bad taste or
smell in their mouth? Yes No
Mental Health and Substance Use
5. Did the member use tobacco products (including * 6. Has the member used tobacco products (including
cigarettes or e-cigarettes) before this pregnancy? cigarettes or e-cigarettes) during this pregnancy?
Yes No Yes No
If yes, record what tobacco products the member used. If yes, record what tobacco products the member
used.
7. Does anyone in the member’s household smoke or use 8. Did the member drink alcohol in the three months
tobacco products? before their current pregnancy?
Yes No Yes No
If yes, about how many drinks did they have per week?
* 9. Has the member drunk alcohol during this * 10. In the past year, has the member used drugs that
pregnancy? weren’t prescribed to them or used drugs in a way
other than how they were prescribed?
Yes No
Yes No
If yes, about how many drinks do they have per
week?
* 11. During the past month, has the member lost * 12. How does the member rate their current stress
interest in doing things or been bothered by level?
feeling down, depressed, or hopeless?
High Medium Low
Yes No
* 13. Does the member have concerns about their mental health or substance use? Yes No
(Optional) If yes, describe the concerns.
Environmental and Social Factors
* 14. Has the member had any housing concerns in the * 15. Does the member feel safe where they live?
past three months?
Yes No
Yes No
* 16. In the past month, has the member had to skip * 17. Does the member have any problems that stop
any meals, not eaten when they were hungry, or them from getting to their health care or social
used a food pantry because they did not have services appointments (for example, problems
enough money for food? with transportation or with getting childcare)?
Yes No Yes No
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F-01105 (07/2024)
* 18. Has the member ever been physically, sexually, * 19. Does the member have people in their life that
emotionally, or verbally abused by their current they can count on when they need help?
partner, an ex-partner, or anyone close to them?
Yes No
Yes No
20. Who can the member count on for help with everyday activities like childcare, cooking, laundry, or transportation?
Member Needs
21. Is the member very worried about any of the following? Check all that apply.
Money problems Labor and delivery
Their own job, unemployment, or education Caring for this baby
Their partner’s job or unemployment Caring for their other children
Their own drinking or substance use Stable housing / food
Drinking or substance use by someone else in Difficulty accessing medical or social service
their household support
Their relationship with their partner Social and community network
Their partner didn’t want this pregnancy Access to transportation
Other:
22. Which concern from Element 21 is the member most worried about?
23. How does the member cope with their problems, and how has the member overcome problems in the past?
24. What topics would the member like to learn more about? Check all that apply.
Alcohol’s effect on their health and their baby’s How to stop using tobacco products
health
How to be more comfortable during the
Baby growth and development pregnancy
Breastfeeding Labor and delivery
Caring for their newborn Nutrition during and after the pregnancy
Family planning and birth control Managing stress
Getting health care for themselves or their baby Other:
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25. Additional Information
SECTION V – ELIGIBILITY AND SIGNATURE (To be completed by PNCC agency care coordinator, qualified
professional reviewer, and member.)
* 1. Is the member fluent in and comfortable with English? Yes No
2. Is the member eligible for PNCC services? If yes, why?
Yes, because:
They have four or more risk factors. Their total number of risk factors is: .
They are years old.
No
3. Name – Care Coordinator Completing Questionnaire
4. SIGNATURE – Care Coordinator 5. Date Signed – Care Coordinator
6. Name – Qualified Health Professional Reviewer (If different from above)
7. SIGNATURE – Qualified Health Professional Reviewer 8. Date Signed – Qualified Health
Professional Reviewer
9. SIGNATURE – Member 10. Date Signed – Member
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