USA xxx-xxx-xxxx
Date Format :- MM-DD-YYYY

Are you a US citizen/resident?
Yes   No
Have you delivered a child before?
Yes   No
Have you given birth more than 5 times?
Yes   No
Have you had more than 3 c-sections?
Yes   No
Do you use any illegal substances?
Yes   No
Do you smoke?
Yes   No
Are you receiving Cash Aid assistance?
Yes   No