Initial Screening | Building Blocks Agency

First Name

Last Name

Phone Number

Email

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Street Address

Street Address 2

Country

City

State

Zip Code

Are you a US Citizen?

Are you a Permanent Resident?

Height

'

"

Weight

lbs

Have you had at least one healthy delivery?

Are you currently pregnant or do you plan to have a child within the next 12 months?

Are you at least 6 months post-partum for vaginal delivery, or 12 months post-partum for c-section?

Have you experienced any major pregnancy complications?

Please describe the complication(s).

How many C-Sections have you had?

To your knowledge, do you currently have a sexually transmitted disease or any chronic medical conditions?

Please describe any STDs or chronic medical conditions.

Do you have a history of smoking or drug use?

Please select which form of smoking and/or drug use you have in your history. Check all that apply.

Cigarettes

Vaping

Tobacco Use

Drug Use

Cannabis Use