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Provider Fax Member DOB OB Tax ID # FULL- PRE- EDC LMP GRAVIDA PARA TERM TERM AB L Initial Prenatal Visit Date Primary Language Spoken Current Pregnancy Risks (please check if yes ) Preterm Labor Incompetent Cervix Twins Triplets Gestational Diabetes Placenta previa or vaginal bleeding Preeclampsia or P.I.H. Under age 16 Over age 35 Fetal anomaly specify Psychiatric/emotional disorder specify: Domestic Violence Other Social Challenges speci.

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