Reproductive Health Program Reproductive Health Program

Email:
  weecaremail@utah.gov

Phone:
  SLC area: (801) 538-9943
  Toll free:  (800) 662-9660

FAX:
  SLC area: (801) 538-9233

Mail:
  PEHP WeeCare Program
  P.O. Box 142001
  Salt Lake City UT
  84112-2001




* Required Field

*Please put date in MM/DD/YY
*First Name:
*Last Name:
Nickname:
*Birth Date:

 
*Mailing Address:
*City:
*State:
*Zip Code:
Email Address:

*At least one phone number is required.
Home Phone:
Work Phone:
Other Phone:
Description of Phone:
(ie: cell phone, pager, etc.)

 
Policy Holder's
Full Name:
 
Policy Holder's Identification Number:
Relationship to
Policy Holder:
Policy Holder's
Employer:
Please enter information about additional health insurance policies, if any:

 
*1. Number of Previous
Pregnancies:
If you have not been pregnant before, skip to #4.
2. Did you have any problems or complications with your previous pregnancies?
Yes No
If yes, please
give description: 
3. Did any of the infants have problems or complications?
Yes No
If yes, please
give description: 
4. Do you have any ongoing health concerns?
Yes No
If yes, please
give description: 
5. Do you take any medications, including over-the counter medications, prescription medications, vitamins, herbs, or dietary supplements?
Yes No
If yes, please
list them: 
6. Do you use tobacco products, drink alcoholic beverages, or use any recreational drugs?
Yes No
If yes, please
give description: 
7. Are you aware of any problems or concerns with this pregnancy?
Yes No
If yes, please
give description: 
8. Do you have any questions about your health or any other questions for the WeeCare nurses?
Yes No
If yes, please
give description: 

*You must provide either the "Estimated Due Date" or the "First Day of Last Period", if unknown type "Unknown"
*Please put date in MM/DD/YY
*Estimated
Due Date:
*First Day of
Last Period:
Physician or Midwife's Full Name:
First Prenatal Care Appointment Date:
Anticipated Delivery Hospital:

 
As part of your enrollment in WeeCare, we will schedule you for a brief telephone interview with one of the WeeCare nurses. She will explain the WeeCare program and answer any questions you may have. Please plan on about 10 minutes for the interview. Interview calls are done each week on Monday and Wednesday from 9:00 AM to 11:30 AM and 1:00 PM to 6:00 PM with the last appointment of the day scheduled at 5:30 PM.

Please list your availability below so we can schedule your appointment. (If there are no times on Monday and Wednesday that will work for you, please indicate below, and we will try our best to accommodate you at another time.) Please also indicate what phone number we should use to reach you for your telephone interview.
 
Availability:
Phone Number for telephone interview:

 
We will be sending you an informational packet. In addition, all participants may receive the Baby Your Baby Health Keepsake and a pregnancy book of their choice.
 
Would you like a Baby Your Baby Health Keepsake?
Which book would you like us to send?