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Get Kaiser Permanente 03925-013 2013

ENCE LANGUAGE PREFERENCE MARITAL STATUS n Married n Single n Domestic Partner n Separated n Divorced n Widow OCCUPATION EMPLOYER NAME LOCATION OB/GYN STATUS: First day of your last period: n Yes n No � Are you currently breastfeeding? Planned Delivery Site: PREGNANCY CIRCUMSTANCES: What is your living situation? n With baby’s father n Domestic Partner/Partner n Parents n Relatives n Friends n Alone n Other Spouse/Partner/Significant Other’s Name: Spouse/Partner/Signifi.

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