First, we want to know a little about you: (All your answers will remain anonymous!) Question Title * 1. What's your age? Under 15 years old 15 - 20 years old 21 - 30 years old 31 - 40 years old Above 40 years old Question Title * 2. What's your race/ethnicity? (select all that apply) Black White Asian (including the Indian Subcontinent and Pacific Islander) Native American Hispanic Other (please specify) Question Title * 3. What's your zip code? Question Title * 4. Did you deliver any of your previous children early? Yes, I delivered my previous child (or one of my previous children) early I think so, but I don't remember at how many weeks I delivered my baby No Question Title * 5. If one of your children was born early, at how many weeks did you deliver him or her? (If you did not deliver any of your previous children early, please enter "n/a") Now, some questions about delivering early: Question Title * 6. True or False: A preterm birth is when a baby is born before 37 weeks True False Question Title * 7. Which of the following are risk factors for delivering too early? (select all that apply) African-American or Black ancestry Having delivered a previous child early High blood pressure Talking on a cell phone Question Title * 8. One of your children was born early. You're now pregnant with another baby. Which option can prevent you from having this baby too early? Advil 17OHPC Drinking lots of water I don't know Question Title * 9. Do you think you're at risk for delivering your baby too early? Yes No I don't know Question Title * 10. How comfortable are you with talking to your doctor about preterm birth? Very comfortable Kind of comfortable I don't know Kind of uncomfortable Very uncomfortable Question Title * 11. Is the information in our brochure and website helpful and easy to understand? Yes No Question Title * 12. What else would you like to know about preterm birth? Let us know, and we'll try our best to include this information on our website! Thank you. Your answers will help us educate and empower women, and protect the health of New York's moms and babies! Question Title Submit
