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Notice of Pregnancy

Enter the required information to help us securely confirm your identity.

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My Own Info

Race/Ethnicity (please check all that apply)

American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Declined to Share

What Provider/Clinic is Helping During Pregnancy

My Current Situation

Please check this box if you would answer 'No' to any of the below statements
  • I have a phone.
  • I feel safe at home and with the people in my life.
  • I have enough food for me and my family each day.
  • I feel good about where I live.
  • I have transportation for my daily needs.
  • I am able to pay my utility bills (gas, water, electric, etc.).

My Current Pregnancy Information

Please check all that apply:

Multiples (twins, triplets)
High blood pressure or heart problems
Diabetes (high blood sugar; type I, type II, during pregnancy only)
Very bad nausea and vomiting
Asthma or other breathing problems
Sickle cell
Kidney disease
Seizures/epilepsy
Depression (feeling blue)
Bipolar disorder
Anxiety (feeling worried or stressed)
Substance use (fentanyl, opiates, heroin, crack, cocaine, alcohol, marijuana, methamphetamine)
Tobacco use (smoking cigarettes, chewing tobacco, or vaping)
I do not have any of these
Other health needs

My Past Pregnancy History

Please check all that apply:

Previous delivery before 37 weeks
Gestational diabetes (high blood sugar while pregnant)
High blood pressure in pregnancy/preeclampsia or heart problems
Delivery less than 18 months ago
Taking any form of progesterone
Previous C-section
I did not have any of these or this is my first pregnancy
Other