Today's Date
*
-
Year
-
Month
Day
1
Mother's First Name
*
Phone Number
*
-
Area Code
Phone Number
E-mail Address
*
example@example.com
Baby's First Initial
*
If pregnant, what is your due date?
-
Year
-
Month
Day
Date
How old is your baby today?
*
1 week
2 weeks
3 weeks
1 month
1.5 months
2 Months
2.5 months
3 months
4 months
5 months
6 months
9 months
12 months
> 12 months
I'm Pregnant
How many months do you plan on breastfeeding?
*
1
2
3
4
5
6
9
12
15
18
24
> 24
Where was your baby born?
If you are using formula, when was it started?
How did you hear of Baby Cafe?
Mom's Age
*
Under 19 years
Age 19 to 25
Over 25
What Ethnicity do you identify as?
*
ASIAN
BLACK AMERICAN
BLACK HISPANIC
BLACK OTHER
CAUCASIAN
HISPANIC
INDIAN
NATIVE AMERICAN
OTHER
Are you using the WIC program?
Yes
No
Are you going to work outside the home?
Yes
No
Mom's Highest Level of Education
*
NO HS DEGREE OR GED
HIGH SCHOOL OR GED
COLLEGE DEGREE
POST GRAD DEGREE
IN SCHOOL
Are you....
*
FIRST TIME HERE WITH 1ST CHILD
FIRST TIME HERE WITH 2ND (OR Greater) BABY
RETURNING TO CAFE WITH ANOTHER BABY
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