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1. How many weeks pregnant was your wife/partner when you found out that the baby died?

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2. How many weeks gestation was the baby when it passed away?

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3. How was the baby delivered?

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4. How did you find out that the baby died? (Please check any that apply)

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5. If you had an ultrasound, please check any that apply to your ultrasound experience.

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6. Please check all that apply to your experience of finding out, from your doctor, that the baby had died.

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7. What term did the doctor use when referring to the baby’s death? (Please check any that apply)

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8. What term did the doctor use when referring to your baby? (Please check any that apply)

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9. Were you given information to make a choice on miscarriage at home verses a hospital induction procedure?

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10. Did the doctor offer your wife/partner a D&C surgery?

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