Oglala lakota college head start/early head start

Health & Pregnancy History

Assurance of Confidentiality:
The information on this form is being requested on a
voluntary basis. The information that you provide will help us to deliver or direct
services most appropriate for your family’s needs. Some of the information may be used
to help plan national program initiatives. If you prefer not to provide some of the
information, it will not affect the services we try to deliver. However, some information is
required for eligibility determination. All information will be held in strict confidence.

Date: __________________
Enrollee’s Name: _______________________________________________________
Date or Birth: __________________________ SSN: ___________________________
Address: __________________________ Telephone: _________________________
Marital Status: _____ Single _____ Married _____ Separated ______ Divorced

Is the applicant a teen parent: Yes or No
Current Pregnancy:

Are you currently receiving Prenatal Care: Yes or No If no, please indicate why:
If you marked yes, please fill out the following information:
Month of 1st Prenatal Care visit: _____________ Expected delivery date: ____________
Which trimester is this pregnancy? _______ First _______ Second _______ Third
Have you received an ultrasound? Yes or No
If yes, date of ultrasound: _____________ Date of next scheduled prenatal visit: _________________________________________ P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax) Time between this and last pregnancy: ____ none ____ less than 18 months ____ more than 18 months # of full term births: _____ ____Norplant ____ Diaphragm/Cervical Cap ____ Tubal Ligation ____Oral Contraceptive Pill
____ Other (specify) ____________________________________________________
Service Providers

Where do you receive your prenatal care from?
Prenatal Care Provider: ___________________________________________________
Address: _______________________________________________________________
Telephone number: ______________________________________________________
Date of last pap smear: _______________ None in past 2 years ____Don’t remember
Pap results: ____ Normal
Do you receive services from any of the following sources: ____ Native Women’s Clinic _____WIC _____Indian Health Services _____ Other Are there any services that you presently need: ________________________________ What transportation method do you use for appointments: ________________________ Do you need assistance for transportation to appointments: Yes or No Do you have any chronic or acute medical conditions: P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)
List any known allergies you have: __________________________________________
List any medications that you are presently taking: ______________________________
List any medical conditions you are presently experiencing: _______________________
Assistive Devices Used:

_______ None _______ Glasses/Contact Lenses _______ Hearing Aid _______ Braces
_____ Crutches/Walker/Cane _____ Wheelchair _____ Other (specify) ____________
Risk Assessment
Are you experiencing any complications with this pregnancy:
Have you experienced complications with any other pregnancies? Yes or No If yes, please specify: Complication _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Are there any of the following risk factors present in your current living situation? ____ None _____ toddlers in home _____ lack of social support _____ homelessness ____ Language barrier ____impaired cognitive ability _____domestic violence ____ drug/alcohol use/abuse _____Other (specify) ______________________________ P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax) Are you attending any support or educational groups:
Please specify if yes: ______________________________________________________

Drug Use History

Have you ever attended an alcohol/drug treatment program:
If yes, dates and location: _________________________________________________ Did you successfully complete: Do you feel you presently have a need for alcohol/drug services: Yes or No Please check off which substances you presently use: Substances used
Would you like assistance with seeking services for alcohol/drug use: Yes or No
Do you have any disabilities for which you are presently receiving services? Yes or No
Visual disabilities: Yes or No
Hearing impairment including deafness: Yes or No Orthopedic impairment: Yes or No Speech or language impairment: Yes or No Health impairment: Yes or No Emotional/Behavioral Disorder: Yes or No Traumatic Brain Injury: Yes or No Autism: Yes or No Other impairments: _______________________________________________________ P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax) Primary Occupational Status (mark one) _____ Paying Job __ Other: (specify) ________________________________________________ Highest level of application completed: _______________________________________ Are you willing to pursue educational opportunities: If yes, what assistance would you need in order to pursue these goals (specify): _______________________________________________________________________ _______________________________________________________________________ 1. I declare under penalty of perjury that the information provided is true and correct to the best of my 2. I understand that I will receive a notice of approval or disapproval of my eligibility application. 3. I understand that this certification is not complete until all documentation is submitted and this form has been reviewed, signed, dated by an agency representative and signed and dated by me. 4. I understand there is additional paperwork for me to fill out if my child is approved for Early Head _______________________________________________ _________________________ Signature Date P.O. Box 490 Kyle, SD 57752 / 605-455-6114 (Phone) and 605-455-6116 (Fax)

Source: http://headstart.olc.edu/docs/applications/prntlap11.pdf


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