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Get CO Request for Pregnancy Test 2009-2024

Ro – American Black ____ American Indian/Alaskan ____ Asian ____ Caucasian ____ Pacific Islander ____ Other ZIP How do you feel about becoming pregnant? (Check the best answer). 1. ____ I wanted to be pregnant sooner 2. ____ I wanted to be pregnant later 3. ____ I wanted to be pregnant now 4. ____ I didn’t want to be pregnant then or at any time in the future Are you a smoker? Yes______ No______ ETHNICITY: Hispanic ______Yes ________No 1. Any symptoms of pregnancy? _____Yes _____No If yes.

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