HIGH-RISK MATERNITY PROGRAMNOTIFICATION FORM

To assist you in supporting your patients with complicated pregnancies, please provide us with the information requested in this form. Please notify us if the patient miscarries or develops complications after you submit this form. Thank you.

Date _________________________

PATIENT INFORMATION

Name ______________________________________________________________________ Date of birth _____________________

Address ______________________________________________ City ________________________ State ____ Zip ____________

Phone (home) __________________________ Phone (work) __________________________ Due date _______________________

PROVIDER INFORMATION

Name ______________________________________________________________________________________________________

Address ________________________________________________________________________ Phone ______________________

RISK FACTORS (Past or current – please check all that apply)

Past Current Risk Past Current Risk q q Advanced maternal age q q Placenta previa/Abruptio placentae q q Chronic illness q q Pre-eclampsia q q Deep vein thrombosis q q Pregnancy-induced hypertension q q Diabetes mellitus q q Premature rupture of membranes q q Domestic violence q q Preterm labor q q Gestational diabetes q q Smoking q q Hyperemesis with TPN/HIT q q Substance abuse q q Hypertension q q Teen pregnancy q q Incompetent cervix/cerclage placement q q Toxemia q q Infertility history/IVF q q Uterine abnormalities q q Malignancy q q None q q Multi-fetal pregnancy q q Other__________________________________

Please complete and fax this form to Network Health at 920-720-1903 or mail to:

Network Health1570 Midway Pl.Menasha, WI 54952

If you have any questions, please contact Marilyn at 920-720-1611.c-car-highriskmatfrm-1113