Health/Medical How is your pregnancy going? Listen, ask, and assess for ● Obtaining prenatal care ● Nausea/vomiting ● Heartburn ● Constipation ● Previous pregnancies Is this your first pregnancy? (Not including current pregnancy) # of previous pregnancies # of live births # of pregnancies past 20 weeks/5 months Date of last live birth Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? I'm going to read a list of options. Please choose the one that best describes how you felt. With any past pregnancy did you have any complications? How are you feeling this week? Listen, ask, and assess for ● Nausea ● Vomiting ● Discomfort How do you feel about your weight gain? Have you been to the doctor yet? Care began after 13th week? Tell me about any medical problems or illnesses you have. Has your doctor diagnosed any medical problems? Listen, ask, and assess for ● Medical conditions (previous to pregnancy) ● Health concerns ● Disability ● Illnesses Medical Conditions Are you currently taking any medications? Listen, ask, and assess for ● Medications that compromise nutritional status Do you ever have a hard time chewing or eating certain foods? Listen, ask, and assess for ● Oral health care/Referral ● Tooth decay ● Tooth loss ● Impaired ability to eat ● Gingivitis

Nutrition Practices Tell me what you like to eat and drink. Listen, ask, and assess for ● Appetite ● Timing of Meals ● Meals, snacks and drinks ● Eating pattern ● Frequency ● Eating problems ● Food preparation ● Food likes and dislikes ● Pica What would you like to change about your eating? Is there anything you would like to eat more or less of? In the month before you got pregnant with this baby, how many times a week did you take a multivitamin? Have you taken any vitamins/minerals in the past month? Do you take any herbs or dietary supplements now? Other Nutrition Risks

Life Style Current Nicotine and Tobacco Use Do you currently use any of the following: cigarettes, hookahs/pipes, e-cigarettes, vaping devices, smokeless tobacco, or nicotine replacement therapies? In the past seven days, have you been in an enclosed space (i.e. car, home, workplace) while someone used tobacco products? Cigarette Smoking In the 3 months before you were pregnant, how many cigarettes did you smoke on an average day? (1 pack = 20 cigarettes) Cigarettes/day How many do you smoke on an average day now? Cigarettes/day Past Alcohol Use In the 3 months before you were pregnant, how many alcoholic drinks (beer, wine or liquor) did you have in an average week? Drinks/wk Have you consumed alcohol during this pregnancy? Current Alcohol Use How many alcoholic drinks (beer, wine or liquor) do you have in an average week now? Drinks/wk Current Drug Use Are you misusing any prescription medications, using marijuana in any form or using any illegal substances? Listen, ask, and assess for ● Abuse of prescription medications ● Marijuana in any form ● Any illegal substances What do you do for physical activity? Listen, ask, and assess for ● Physical activities ● Walking ● Playing with children ● Safe parks ● Access to fitness centers ● Activity frequency

BF Preparations What have you heard about breastfeeding? Listen, ask, and assess for ● Interest in breastfeeding ● Myths ● Concerns ● Support systems Mom Interested in Breastfeeding Previous experience If previously breastfed, how did it go? ● Affirm ● Praise Length of time (weeks) Reason for stopping What does your family, friends, or partner say about breastfeeding? Tell me about the changes you have noticed or concerns you have about your breasts. Listen, ask, and assess for ● Flat ● Inverted ● Pierced ● Surgeries ● Pain/discharge ● Size Are you exclusively or mostly (Part BF In-Range) breastfeeding an infant or mostly (Part BF In-Range) breastfeeding multiples from a previous pregnancy? How is breastfeeding going for you? Listen, ask, and assess for ● Successes ● Challenges ● Milk supply ● Teething/biting ● Baby preferring one breast ● Baby not interested ● Soreness/nipple care ● Breasts leaking

Social Environment What else can I help you with? Listen, ask, and assess for ● Abuse/neglect ● Limited ability to make appropriate feeding decisions or prepare foods ● Family planning