Regional Perinatal System


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	Evaluation

Pregnancy Passport
>> Survey

You are a Woman
who has a Pregnancy Passport

Please take 5-10 minutes to answer the following questions based on your experience with the Pregnancy Passport so far. Your feedback is very important to us. Thank you!

	Name (optional)


1)	When did you receive your pregnancy passport?
	Week(s)

2)	How far along in pregnancy are you now?
	Week(s)

3)	Your healthcare provider explain how to use the Pregnancy Passport?
	Yes No

4)	Your healthcare provider discuss the signs of preterm labor with you?
	Yes No

5)	Were you familiar with the signs of preterm labor before you received your Pregnancy Passport? (1= not at all, 5= extremely)


6)	How familiar are you with the signs of preterm labor now? (1= not at all, 5= extremely)


7)	Did your healthcare provider discuss what to do in case you are experiencing warning signs, including signs of preterm labor, with you?
	Yes No

8)	What do you like most about the Pregnancy Passport?
	Instructions on how to use the Passport Prenatal visit record Filling in my medical information Educational information about preterm labor and warning signs Kick count record Prenatal lab test results Definitions of medical terms & labs Resource phone numbers Ways to get involved in your healthcare Other

9)	What do you dislike about the Pregnancy Passport?
	Instructions on how to use the Passport Prenatal visit record Filling in my medical information Educational information about preterm labor and warning signs Kick count record Prenatal lab test results Definitions of medical terms & labs Resource phone numbers Ways to get involved in your healthcare Other

10)	How useful is the Pregnancy Passport to you? (1= not at all, 5= extremely)


11)	Would you recommend the Pregnancy Passport to other women?
	Yes No

12)	Did you ever use the Pregnancy Passport during emergency situation?
	Yes No

12b)	If you would like to, please tell us more about that:


13)	What changes would you suggest making to the content of the Pregnancy Passport?


14)	What changes would you suggest making to the design of the Pregnancy Passport?


15)	Please share any other comments or suggestions you have about the Pregnancy Passport: