Preconception Checklist
Most pregnancies are unplanned; therefore, it is beneficial to assess preconception health with all female patients of childbearing age during routine checkups. It is a way of encouraging healthy habits that can affect pregnancy outcome. The March of Dimes in conjunction with the Greater Adirondack Perinatal Network has developed two unique screening and counseling tools for health care providers to use with their patients. Option 1: Greater Adirondack Perinatal Network
(GAP-Net): Preconception Screening and Counseling Tool
The Greater Adirondack Perinatal Network has developed a unique screening and counseling tool (with funding from the March of Dimes) to be used with patients in assessing their health needs before conception. Providers can utilize the Two-Way Preconception Screening and Counseling Tool to increase preconception counseling within their practice and help ensure that patients are healthy before pregnancy. Most pregnancies are unplanned; therefore, it is beneficial to use this form with all female patients of childbearing age during routine checkups. It is a way of encouraging healthy habits that can affect pregnancy outcome. The tool, created and piloted in 2000, was developed in response to provider requests for a consistent, active approach to increasing client acceptance and demand for preconception services. Highlights:
- The tool is a two-part form. The top page, a self-assessment checklist completed by the patient, is easily inserted into the chart. The bottom page is a take-home section for the patient with key health education messages.
- The patient can complete the top page in five minutes. It is divided into seven categories: Diet & Exercise, Medication/Drugs, Women's Health, Home Environment, Lifestyle, Medical/Family History, Genetics.
- Providers can easily interpret the patient self-assessment portion, which contains ample space for provider notes. The provider note, written on the top page, transfers to the bottom page, which the patient takes home.
The Greater Adirondack Perinatal Network tool can be ordered in multiples of 100 at the price of $35 per 100.
To order a supply of the Two-Way Preconception Screening and Counseling Tool:
Call 518-761-0300, ext. 217 or
Send order and payment to:
Greater Adirondack Perinatal Network
P.O. Box 3253
Glens Falls, NY 12801
Attn: Tool Order
Option 2: Free March of Dimes Checklist
Just Download and Use
To help providers get started right away, we offer the March of Dimes Preconception Screening and Counseling Checklist, a revision of the Two-Way Preconception Screening and Counseling Tool updated by a panel of experts at the March of Dimes. The checklist does not include the patient education section.
Providers can use this one-pager to initiate discussions about preconception care. This list offers a series of essential questions that help providers develop good clinical management plans. Patients are given the checklist at the reception desk and are asked to fill it out before seeing the provider.
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