St. Elizabeth's Maternity – Maybe Baby Quiz
First Name
Are you taking folic acid or a prenatal vitamin?
- None -
Yes
No
Last Name
Street Address
City
State
Zip Code
Email Address
Are you thinking about having a baby or another baby?
- None -
Yes
No
Have you reduced or given up caffeine intake?
- None -
Yes
No
Have you spoken with your physician about going off your birth control?
- None -
Yes
No
If you smoke, have you taken steps to quit?
- None -
Yes
No
Are you ready to look at your diet and consider changes for a healthier you?
- None -
Yes
No
Have you seen an OB/Gyn for prenatal counseling?
- None -
Yes
No
How did you hear about us?
- None -
Friend / Relative
Web
Print Ad / Radio Ad
Attended an Event
Physician Referral
Other
Would you like to receive periodic email information about gynecology and maternity services?
- None -
Yes, please send me periodic information and updates.
Leave this field blank