Healthy Families Rappahannock Area Questionnaire
Email address *
Mother's Name *
Your answer
Date of Birth *
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Address *
Your answer
I live in: *
Phone Number *
Your answer
My preferred method to be contacted is: *
My babies father's name is: *
Your answer
His date of birth is: *
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DD
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I am completing this survey: *
My baby's name:
Your answer
Please enter your baby's DOB or expected DOB *
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My first prenatal visit was between
Right now i am:
I am currently:
My income is sufficient to meet my needs
I currently receive the following assistance:
Is your family (including the father of the baby) happy and supportive of this pregnancy?
I have serious family stress:
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