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SECOND VISIT
Name
Last Name
Email
Age
Race
White
Black
Native American
Asian Indian
Multiple races
Other
Ethnicity
Non-Hispanic
Mexican
Puerto Rican
Cuban
Central / South American
Other
How many Live Births have you had??
How many total Births have you had (including stillbirths)?
How many C-Sections have you had?
Have you had diabetes before pregnancy?
Yes
No
Have you had hypertension (high blood pressure) before pregnancy?
Yes
No
Height (ft)
Pre-pregnancy weight (lbs)
Number of cigarrettes smoked daily before the pregnancy
Were you diagnosed with Gestational Diabetes (diabetes aquired during pregnancy)
*
Yes
No
Were you diagnosed with Gestational Hypertension during pregnancy (Hypertension-high blood pressure aquired during pregnancy)
*
Yes
No
Gestational age in weeks
*
35
36
37
38
39
40
Your weight gain during pregnancy (lbs)
Number of visits - times you have seen clinician in this pregnancy?
SUBMIT
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