Maternal Child Health Survey
City of York - Bureau of Health
Date
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Month
-
Day
Year
Date Picker Icon
Are you
*
Pregnant
Mom of 0-2 year old
Father of the baby
Friend/family member
Other
On a scale of 1 to 5, how would you rate your health before you were pregnant?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
On a scale of 1 to 5, how would you rate your health now?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Have you been visited by our mom/baby nurse?
Yes
No
What is the safest sleeping position for a baby?
*
On his belly
Propped up with a pillow
On his side
On his back
How do you feel about your:
*
Rows
Very Satisfied
Satisfied
Somewhat Satisfied
Not Satisfied
Does not apply
Family/friends
House
Safety
$ $
Reading ability
Job
Car
Are you breastfeeding or planning to breastfeed?
*
Yes
No
Undecided
Not applicable
Which of these are ok during pregnancy? (You may check more than one box.)
*
Cigarettes
Tylenol
Fruit juice
Wine
Beer
Coffee (5 cups/day)
Marijuana
Cannabis oil
Energy drinks
Taking a nap
Heroin
Aspirin
Birth control
Molly/Ecstasy
None of these
How would you describe your race/ethnicity (You may check more than one box)?
Black/African American
American Indian/Native Hawaiian
White/Caucasian
Hispanic
Unknown
Prefer not to answer
Other
What two things do you feel you need the most at this time?
Rate your experience with Healthy Moms Healthy Babies (5 stars is the highest rating)
*
1
2
3
4
5
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*
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