OBSTETRICAL NEEDS ASSESSMENT FORM (ONAF) 226 INSTRUCTIONS FOR COMPLETIONThis form is intended for Medicaid Recipients participating in a HealthChoices Managed Care Organization (MCO) or the Fee for Service delivery system. þ þ þ þ 5. þ Please attach additional information if necessary. þ þ Visit (Fax at these times)Section to CompleteFirst prenatal visitNew Practice name Phone # and Fax # SM1st Prenatal Visit þ þ GravidaPre-term American LegalNet, Inc. www.FormsWorkFlow.com 17P CandidateReferral American LegalNet, Inc. www.FormsWorkFlow.com OBSTETRICAL NEEDS ASSESSMENT FORM (ONAF) PhoneFax Home Phone1st Prenatal Visit GravidaPre-TermHeight Positive Pre-Pregnancy 1st Trimester2nd Trimester3rd Trimester 1st Schizophrenia Trait 1st HxHomelessnessatGestation Hx Vag Vertex Rx Hx Street HxOpioid TherapyVisitFeeding PP Contraception Contraception Plan MA 552 10/18