Health Center
Client Number
Date Of Visit
(MM/DD/YYYY)
FIPS Code
Ethnic Origin - Hispanic Yes | No | Unk
Interpreter Yes | No
Gender Female | Male
Previous pregnancies
Live births
Age at first pregnancy
Age at first live birth
Last pregnancy ended (MM/YYYY)
Preg desired w/in year Yes | No
Currently In School Yes | No
Date Of Birth
(MM/DD/YYYY)
Monthly Family Income
Family Size
BMI Edu Yes | No
Condoms Yes | No
ECP Future Yes | No
ECP Today Yes | No