Maternal Health Home Assessment
General Information
Date of Assessment
Assessor Name
Client Name
Age
Pregnancy Information
Gestational Age (weeks)
Estimated Due Date
Parity (Number of previous pregnancies)
Medical History
Medical Conditions
Current Medications
Allergies
Home Environment
Living Conditions
Water Supply & Sanitation
Physical Assessment
Blood Pressure (mmHg)
Pulse (bpm)
Temperature (°C)
General Exam Notes
Social Support
Family Support
Community Resources Accessed
Education/Counseling Provided
Recommendations & Plan