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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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