Member Name  *

Member ID  *

EDC

Address  *

City  *

State

ZIP Code

Phone Number  *

Provider Phone Number

Obstetrician Name  *

Email

Did member's last pregnancy result in C-section?

Did member's last pregnancy result in a miscarriage?

Did baby weigh less than 5lb. 8oz.?

Was the baby born more than three weeks early?

Did the baby stay in the hospital after mother was discharged?

Current episode of preterm labor

Previous preterm labor

Mutiple gestation this pregnancy

Use of tobacco products since last menstrual period

Use of any beer, wine, wine coolers or liquor since last menstrual period

Known history of cocaine, marijuana, or street drugs during this pregnancy

Incompetent cervix with cerclage

Uterine abnormality

Chronic hypertension

Diabetes mellitus at conception, insulin dependent

Diabetes mellitus at conception, non-insulin dependent

Infertility Meds/Assisted Reproductive Technology to achieve pregnancy

Other cause for medical concern

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