Get Maternal Health History--part C-1 (dhhs 3963c-1) -- English

The Maternal Health History--Part C-1 (DHHS 3963C-1) form is a vital document used to assess the psychosocial background of a maternal patient. Completing this form accurately can support health professionals in providing the necessary care and resources to individuals during their pregnancy journey.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Maternal Health History--Part C-1 (DHHS 3963C-1) form and open it in the editor.
2. Begin filling out the form by entering your last name and first name in the designated fields at the top of the document.
3. For the patient number, input your unique identifier provided by the healthcare facility.
4. Fill in your date of birth using the format MM/DD/YYYY, making sure to enter the month, day, and year correctly.
5. Select your race by checking the appropriate box from the options provided, including American Indian or Alaska Native, Asian, Black/African American, Native Hawaiian/Other Pacific Islander, Unknown, or White.
6. Next, indicate your ethnic origin by checking the applicable box such as Hispanic Cuban, Hispanic Mexican American, and so on, or select Not Hispanic/Latino or Unreported.
7. Select your gender by marking either Female or Male in the provided checkbox.
8. In the next section labeled ‘Initial Psychosocial Screening’, answer the questions by marking an 'X' or checking the box for Yes or No as it applies to you.
9. Once all questions have been filled in, sign and date the form in the designated areas to certify that the information provided is accurate.
10. Lastly, you can save the changes, download the completed form, print it out, or share it as necessary.

Complete the Maternal Health History--Part C-1 (DHHS 3963C-1) form online today to ensure you receive the support you need during your pregnancy.