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Polytechnic University of The Phillipines: Anonas St. Sta. Mesa Manila

This document contains a prenatal risk profile form for respondents to fill out regarding their pregnancy. It collects information such as parental age, economic status, social status, educational level, birth order, and location. It also contains a checklist for the mother to indicate if she experienced any physical diseases, infections, bleeding, or took any medications during her pregnancy that could impact prenatal risk. Some specific items addressed include preeclampsia, gestational diabetes, hypertension, nausea, infections like influenza and rubella, prenatal medication use, chemical exposures, and mental diseases like schizophrenia.

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Sherlyne Carrillo
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37 views

Polytechnic University of The Phillipines: Anonas St. Sta. Mesa Manila

This document contains a prenatal risk profile form for respondents to fill out regarding their pregnancy. It collects information such as parental age, economic status, social status, educational level, birth order, and location. It also contains a checklist for the mother to indicate if she experienced any physical diseases, infections, bleeding, or took any medications during her pregnancy that could impact prenatal risk. Some specific items addressed include preeclampsia, gestational diabetes, hypertension, nausea, infections like influenza and rubella, prenatal medication use, chemical exposures, and mental diseases like schizophrenia.

Uploaded by

Sherlyne Carrillo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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POLYTECHNIC UNIVERSITY OF THE PHILLIPINES

ANONAS ST. STA. MESA MANILA


Part 1 : Prenatal Risk Profile of the Respondent
Direction: Please filled-up the following items.
Parental Age : Economic Status :
Paternal Age : Social Status :
Maternal Age : Educational Level :
Birth Order : Location / City :
Direction: Please put a check mark (P) in the box if the mother experienced during pregnancy .
Maternal Physical Diseases Personality Disorder
Maternal prenatal
Preeclampsia
medication use
Maternal Gestational Diabetes Antiepileptic drugs
Hypertension/edema Psychotropic drugs
Nausea / Vomiting Antidepressant drugs
Other maternal diseases including
psoriasis, asthma, fever, atopic
Paracematamol
dermatitis, rheumatoid arthritis, celiac
disease, and mastocytosis
Maternal bleeding during pregnancy Antipyretics
Infections during pregnancy Thalidomide
Bacterial infection Misoprostol
Exposure to Certain
Viral infection
Chemicals Heavy Metal
Influenza Pesticides
Rubella Air pollutants
Familial Socioeconomic
Cytomegalovirus
Status
Measles Mother born abroad
Cigarettes or alcohol
Mumps
addiction
Maternal iron, folate,
Chicken pox
methionine deficiency
Herpes virus Maternal vitamin deficiency
Weight gain during
Pneumonia
pregnancy
Syphilis Threatened abortion
Maternal Mental Diseases
Schizophrenia
Depression
Anxiety and stress

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