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How old are you? *
Marital Status *
If in a relationship, how long have you been together?
Employment Status (if/when maternity leave is over) *
Household income:
Yearly household income (optional)
Do you have an insurance plan?
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If yes, does your plan have a cash spending account?
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How many children do you have? *
Have you ever lost a child (miscarriage/stillborn/SIDS)?
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