**NOTE: This is just a preliminary screener application. You will be provided with a full application upon receipt of this form**
Are you employed?*
If you have answered yes, what is your occupation?
Is he/she employed?
If you have answered yes, what is his/her occupation?
Are you married?
If yes, when was your wedding date?
For each of these children, please provide the following info (Name, DOB, Sex, Birth Weight):
Were any of your children delivered via C-section?
Were all of your children born healthy?
If you have answered no, please explain:
Do you enjoy being pregnant?
Do you intend to add more children to your own family?
Have you ever had any abortions, miscarriages or stillbirths?
If you have answered yes, please describe the timing and circumstances of each:
Were any of your children born prematurely or were there any complications with delivery?
If the answer is yes, please describe the circumstances of each birth:
Are you currently on birth control?
If so, what type?
Do you currently take any other prescription medications?
If you have answered yes, please list the name, the dosage, the purpose of each medication, and whether or not you were on the medication during previous pregnancy(ies)
Have you ever been diagnosed with any of the following (please check all that apply):
Blood-clotting conditionDepressionGestational DiabetesHPVHerpesHepatitis (any form)HyperthyroidismPre-eclampsiaSTDsOther
If you have checked any of the above, please explain:
Do you currently smoke?
Do you currently use illegal drugs?
Do you currently drink alcohol?
If yes, how many drinks (on average) per Day:
If yes, how many drinks (on average) per Week:
If yes, how many drinks (on average) per Month:
Date of last OB visit:
Do you have health insurance?
If yes, name of your insurance company
How did you hear about us?
Is there anything else you would like to add?