Background Questions:

1. Age:
    
2. Date of birth: mm/dd/yyyy
    
3. Marital status? Single Married Divorced Separated
    
4. Occupation?
    
5. What is your highest level of education?
    
6. Height: feet inches
    
7. Weight: lbs.
    
8. Eye color: Blue  Brown  Green  Hazel
    
9. Natural hair color: Black  Brown  Blonde  Red
    
10. Ethnic background (e.g., German, French)?
     
11. Have you ever been pregnant?
    No Yes
    How many times?
     
12. Have you given birth to a child (ren)?
    No Yes
     
13. If yes to #12, have you ever had a c-section?
    No Yes
     
14. Did you have any complications with the birthing process?
    No Yes
     
15. Have you ever been hospitalized (excluding childbirth)? 
    No Yes
    (When/Why)
     
16. Do you, or any member of your family, have any history of congenital abnormalities or genetic disease that run in your family? Please be specific.
    No Yes
    (Who/What)
     
17. Are you currently taking any medication? 
    No Yes
    (Type)