S. No.

QUESTION

RESPONSE

1.

Age at first pregnancies (years):

2.

Number of pregnancies (gravid):

3.

Parity:

4.

Number of living children:

5.

Age of the youngest child:

6

Birth interval in months (between the current pregnancy and the previous child)

7.

History of abortion:

[1] Yes

[2] No

8.

History of bleeding during the current pregnancy:

[1] Yes

[2] No

9.

History of preterm birth:

[1] Yes

[2] No

10.

Gestational in weeks: