Inova BabyNET 2010 Personal Needs Survey

Page 1 of 3     Pregnancy information and history   If you tell us a little about yourself and your pregnancy history, we can address any specific concerns or questions you may have. As always, this information stays completely confidential.   1. What is your name?*         2. How did you hear about Inova BabyNET? You can check more than one answer.   On InovaNet   In my paycheck   A flyer in my workplace   From a manager or supervisor   From someone in Inova BabyNET   From someone I work with (not in Inova BabyNET)   At orientation   Other, please specify               3. What language(s) do you speak at home? You can check more than one answer.   English   Spanish   Other, please specify               4. What language would you like to receive Inova BabyNET information in?*   English   Spanish       5. What is your date of birth?*   mm/dd/yyyy       6. What is your due date?*   mm/dd/yyyy       7. Who is your OB Provider         8. At which hospital will you deliver your baby?*   Inova Fairfax Hospital   Inova Alexandria Hospital   Inova Fair Oaks Hospital   Reston Hospital Center   Loudon Hospital Center   Virginia Hospital Center (Arlington)   Other, please specify               9. How many babies are you currently pregnant with?* Please indicate if you are having a single birth, twins, triplets etc.   One   Two   Three   Four   Five or more   Don't know yet       10. At any point during this pregnancy have you experienced and/or been treated for preterm labor?*   Yes No       11. How many previous pregnancies have you had?* Do NOT include this pregnancy.   -- Please Select -- None One Two Three Four or more       12. How many babies have you previously had?* Do NOT include this pregnancy   -- Please Select -- None One Two Three Four or more       13. Breast, bottle or both? How are you going to feed your baby(ies)?* You may check all that apply.   Breastfeed exclusively   Breastfeed and pump   Breastfeed and supplemental formula   Formula only   I haven't decided   Other, please specify               14. During your previous pregnancy or pregnancies; have you EVER had:* Please check all that apply. Make sure to check N/A or NO if none of these conditions apply to you.   early or premature labor   early or premature birth   c-section delivery   two or more miscarriages   twins, triplets or more   None of the above or N/A   Other, please specify               15. If you checked any of the boxes above and would like to provide an brief comment or question, please do so below:         16. Did you use assisted reproductive techniques to achieve this pregnancy (IVF, etc)?*   Yes No