Name:
Address:
Date of interview:
Do you drink or smoke?
Are you periods regular?
How long is your average cycle?
How long do your periods last?
What was the date of your last menstrual period?
Are you taking any prescription or over the counter medications?
Do you have allergies?
Do you have any chronic health conditions?
Have you been exposed to any infections?
Did you have any childhood illnesses or serious illness?
Have you been pregnant before?
Have you had an abortion or miscarriage?
Have you had an induced abortion?
Do you have a baby?
How long was your labor?
Did you have a vaginal or cesarean delivery?
What was the baby's birth weight and size?
Were there any unexpected complications?
Did your baby have a birth defect?
Did you have any problems conceiving?
What symptoms of pregnancy have you experienced?
What is your work environment like?
Are you exposed to any toxic substances at your workplace?
Is your job dangerous?
What is your ethnic background?
What is the ethnic background of the father?
Are there any illnesses that run in either of your families?
Is there a history of twins or multiple pregnancies in your families?
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