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Pregnancy Intake Form
Last Revised 01/26
Appointment
*
Is this your first visit?
*
Please Select
Yes
No
Office Use Only
E#___________________
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What is the best way to contact you?
Email
Mail
Phone
Text
How many people live in your home?
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Date of Birth
*
Sex
*
Please Select
Male/Masculino
Female/Femenino
Not Applicable/No aplicable
Ethnicity
*
Please Select
African/Africano
African American/Afroamericano
Asian/Asiático
Caribbean/Caribeño
Caucasian/Caucásico
East Indian/Indio oriental
First Nations/Primeras Naciones
Haitian/Haitiano
Hispanic/Hispano
Jewish/Judío
Middle East/Medio Oriente
Native American/Nativo americano
Other/Otro
Primary Language Spoken
*
Last Four Digits of Your SSN
How Did You Hear About Us?
Please Select
Website/Sitio web
Friend/Relative/Amigo/Familiar
Television/Televisión
Facebook
Other Social Media/Otras redes sociales
School/Escuela
Agency/Agencia
Return Client/Cliente recurrente
Church/Iglesia
Hospital (Mercy)/
Hospital (Baptist)
What Outside Help Are You Receiving?
*
Child Support
Church
Disability
Employment
Friends
Medicaid
On Maternity Leave
Parents
SNAP
Spouse
SSI
TEA
Unemployment Benefits
WIC
Other
What are your living arrangements?
*
Please Select
Alone
Shelter
Parents
Fiance
Boyfriend
Spouse
Friend
Foster Parents
Father
Grandparents
Other
Mother
What is parents' marital status?
*
Please Select
Engaged
Remarried
Married
Single
Separated
Never Married
Living Together
Widowed
Divorced
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How old were you when you became sexually active?
*
Have you been tested for a sexually transmitted disease (STD)?
*
Please Select
Yes
No
If you have/had any STD's please check all that apply.
AIDS
Chlamydia
Crabs
Genital Warts
Gonorrhea
Herpes
HIV
HPV
Syphilis
Other
Are you a victim of abuse?
*
Please Select
Yes
No
If yes, please select all that apply.
Mental
Verbal
Physical
Rape
Sexual
What is your current relationship with God?
*
Please Select
Close
Desire to be better
Okay
None
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Income Level
*
Please Select
Dependent
Unemployed
Welfare/SSI
$0-$14,999
$15,000-$29,999
$30,000-$44,999
$45,000-$59,999
$$60,000+
Marital Status
*
Please Select
Married
Divorced
Engaged
Living Together
Never Married
Remarried
Separated
Single
Widow
Religion
*
Please Select
Atheist
Buddhist
Christian
Catholic
Hindu
Jehovah's Witness
Jewish
Mormon
Muslim/Islam
Native American
None
Other
Sikhism
WiCCA
Student Status
*
Please Select
Middle School
High School
College/University
Not Student
Trade School
Other
Education (Highest Level Completed)
*
Please Select
Less than high school
High school or GED
Some graduate school
Some College
College graduate
Completed graduate school
Trade school
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Pregnancy History
Number of Prior Births
*
Number of Prior Abortions
*
Number of Prior Miscarriages
*
How many children do you have that are under 3 years?
*
Partner History
What is the potential father's name and age?
*
If the test is positive, will he be involved?
*
Please Select
Yes
No
Maybe
Are you planning a future with him?
*
Please Select
Yes
No
Maybe
Does he know that you might be pregnant?
*
Please Select
Yes
No
What is your current relationship with the father?
*
Please Select
Boyfriend
Fiance
Friend
Husband
Other
What is your plan if the test shows positive?
*
Please Select
To Parent
Adoption
Terminate Pregnancy
Undecided
Do you have a current OB?
*
Please Select
Yes
No
If yes, what is the name of your OB?
I understand and agree to the following:
I release H2H from any liability from any accidents, incidents, or harm from any item received at H2H. I take FULL responsibility of the items I have received from Heart to Heart Pregnancy & Family Care Center. I certify that, to the best of my knowledge, the information I have provided is true and accurate.
Initials
*
Signature
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