Pregnancy Survey
Amerigroup wants to help you have a healthy pregnancy and a healthy baby. The more we
know about your personal health needs, the more we can do to help you get the best care. You
may have already been contacted to conduct a pregnancy survey. If so, you do not need to do
anything. If you have not been contacted, taking a few minutes to complete the following
survey is an important step in helping us help you.
We know some of the following questions are sensitive. Your response to these questions will
be entered into your record so our case manager can assist you during your pregnancy. The
information will only be viewed by employees who are involved in your care. Your responses
will help your case manager educate you on issues you should discuss with your doctor and
help ensure you have a safe delivery.
Please fill in the following information:
Full Name: __________________________________________
Date of Birth:________________________
Street Address: _____________________________________________________________
City, State ZIP: __________________________________________________________________
Phone Number: _______________________________________________________________
Preferred language: _____________________________________________________________
Have you received your Amerigroup membership ID cards?
 YES  NO
Have you picked a doctor to provide your prenatal care?
 YES  NO
If yes, please provide the following information:
Obstetrics (OB) Doctor’s Name: _______________________
Address:_________________________________________________________________
What was the date of your first prenatal care appointment for this pregnancy?
Date: _________
Have you picked a pediatrician to take care of your baby?
 YES  NO
If yes, please provide the following information:
Baby’s Doctor’s Name:_______________________
Address:_________________________________________________________________
Current and Past Pregnancy Questions
Check the box that applies or fill in your answer in the space provided.
1. When is your baby due? Please enter date: ___________________
2. Are you carrying more than one baby now?
3. Is this your first pregnancy? (If yes, SKIP questions 5,6, 7 and 8)
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 YES
 YES
 NO
 NO
4. Have you had preterm labor during this pregnancy?
5. Have you ever had preterm labor during any previous pregnancies?
6. Have you ever given birth to a baby more than three weeks before your due
date?
7. Have you ever given birth to a baby that weighed less than five pounds?
8. Have you ever had a C-section?
9. Have you had to go to the emergency room during this pregnancy for a
pregnancy-related problem?
10. Have you been admitted to the hospital during this pregnancy for a
pregnancy-related problem?
General Health Questions
11. How tall are you? Feet________ Inches________
12. How much did you weigh at the start of your pregnancy? __________lbs
13. Have you ever been told that you had any type of diabetes?
14. Do you currently have any of the following health conditions?
Asthma
High blood pressure
Do you have any other health conditions not named above? Please list them
in the space provided:
______________________________________________
______________________________________________
The next question is about your race and ethnicity. Some ethnicities are at greater
risk for complications during pregnancy.
15. Would you tell me the race you classify yourself as?
___Asian
___American Indian or Alaska Native
___Other
___Choose not to answer
16. During the past month, have you often been bothered by feeling down,
depressed, or hopeless?
17. During the past month, have you often been bothered by little interest or
pleasure in doing things?
18. Have you seen a dentist in the last six months?
19. Have you enrolled in Women, Infants and Children or WIC?
These next few questions are very personal, but your answers can help us better
serve you.
20. Have you had a sexually transmitted disease in the past year?
21. Have you been told you are HIV positive?
If yes, have you received counseling?
22. Have you ever been emotionally or physically abused by your partner or
someone important to you?
 YES
 YES
 YES
 NO
 NO
 NO
 YES
 YES
 YES
 NO
 NO
 NO
 YES
 NO
 YES
 NO
 YES
 YES
 NO
 NO
 YES
 NO
 YES
 NO
 YES
 YES
 NO
 NO
 YES
 YES
 YES
 YES
 NO
 NO
 NO
 NO
___White
___Black or African American
___Hispanic or Latino
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23. During the past year, have you used cigarettes or other tobacco products?
If interested, there is a free resource called the Georgia Tobacco Quitline. The
program can help pregnant women deal with tobacco cravings and other
challenges, as well as quit for good. The number is 1-800-Quit-Now or
1-800-784-8669.
24. Have you ever experimented with illegal drugs?
 YES
 NO
 YES
 NO
Submit
Thank you for taking the time to complete this survey. Your answers will help us provide you
with the best service possible. You may receive a call from a nurse to follow up. If you have any
questions about this survey or if you need help finding an OB provider, please call Member
Services toll free at 1-800-600-4441. Members who are deaf or hard of hearing can call the
AT&T Relay Service toll free at 1-800-855-2880.
Also, you are now enrolled in a special program for pregnant members called Warm Health.
Warm Health will call you twice a week to share brief, timely, pregnancy tips. Many moms find
these calls uplifting and helpful. You can also have messages come to your cell phone via our
Warm Health Texting program or Warm Health App. If you prefer to receive these tips via text,
visit warmhealth.com to sign up.
If you prefer to receive your tips via our app, search for Warm Health in the iTunes App Store or
the Android Marketplace. Visit warmhealth.com to learn more about all of your options.
Thank you for choosing Amerigroup.
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