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First Name(required)
Last Name(required)
Date of Birth(required)
City and State(required)
Your Cell Phone Number for Text and Message(required)
Your Email Address(required)
Your Immigration Status: Citizen, Green Card or Others?(required)
Your Height(required)
Your Weight(required)
Total Number of Pregnancies? (required)
Total Number of Live Births?(required)
Did you have a healthy reproductive history during your previous pregnancies and births? (required)
Has it been more than 6 months since your last birth?(required)
How many cesareans you have undergone?(required)
Have you taken medication(s) for Psychiatric or Psychological diseases within the last 12 months? (required)
YES
NO
Do you smoke?(required)
YES
NO
Do you consume marijuana products?(required)
YES
NO
Have you used recreational drugs, such as heroin, cocaine, barbituates, etc.?(required)
YES
NO