1.	How many pregnancies have you had in total? (Including miscarriages): ______
2.	How many babies born to you in total? _______ How many living children do you have? ______
3.	How many vaginal births have you had? _______ How many cesarean sections have you had? _____
4.	Do you have a history of any of the following? (Check all that apply)
□	Sexually transmitted infection (for example, gonorrhea, chlamydia, HPV or syphilis?)
□	Hepatitis Type B or Type C?
□	Have you ever received a blood transfusion?
□	Have you ever used drugs with needles outside of a hospital? (e.g. heroin, cocaine)
5.	Have you ever been tested for HIV (Please check one)
□	Yes
□	No
□	Do not know
6.	Have you been tested for HIV in this pregnancy? (Please check one)
□	Yes
□	No
7.	Are you HIV-positive (Please check one)
□	Yes
□	No
□	Do not know
8.	Have you ever been treated for HIV (Please check one)
□	Yes
□	No