1. Personal Information

* 3. What city and state/province do you live in (non-U.S.)?

* 5. What type of community are you from?

* 6. What is your race/ethnicity?

* 9. What is your family's religion?

* 10. Has either of your parents passed away?

* 11. If yes, please check the appropriate space.

* 12. Have you ever been pregnant?

* 13. Do you have a child?

* 14. If yes, how many children do you have?

* 15. If yes, what age is your child/children?

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