Placenta Previa Assessment Form
Placenta Previa Assessment Form – Please complete the following non-sensitive screening questions to assist with assessment.
Patient Initials
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gestational Age (weeks)
*
Current Symptoms (select all that apply)
*
Vaginal bleeding
Abdominal pain
No symptoms
Other
Number of prior pregnancies (gravida)
*
Known risk factors (select all that apply)
*
Previous C-section
Multiple gestation
Advanced maternal age
Smoking
No known risk factors
Other
Date of most recent ultrasound
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Placenta previa confirmed on imaging?
*
Yes
No
Not assessed yet
Symptom severity rating (1 = mild, 5 = severe)
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Follow-up needs and next steps
Rows
Needed
Already arranged
Not needed
Repeat ultrasound
1
2
3
Specialist referral
4
5
6
Patient education
7
8
9
Additional labs
10
11
12
Submit Assessment
Should be Empty: