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name(first only)
 
 
Other
 
 
 
 
Age?
 
15-20
 
21-26
 
27-32
 
33-40
 
 
 
blood type?
 
A
 
B
 
AB
 
O
 
 
 
Charge ?
 
+
 
-
 
 
 
Are you have been pregnant before ?
 
yes
 
no
 
 
 
are you now pregnant ?
 
yes
 
no
 
 
 
at what month (if yes) ?
 
 
Other
 
 
 
do you have any chronic disease ?
 
yes
 
no
 
 
 
are you now pregnant ?
 
yes
 
no
 
 
 
name(first only)
 
 
Other