Health/Medical How is it being a new mom? Listen, ask, and assess for ● Postpartum depression ● Struggles ● Successes ● Caregiver ability What concerns do you or your doctor have about your health? Listen, ask, and assess for ● Medical conditions ● Family planning Any medical conditions, illnesses, or special needs? Medical Conditions Are you currently taking any medications? Listen, ask, and assess for ● Medications that compromise nutritional status Was this your first pregnancy? (Not including most recent pregnancy) # of previous pregnancies # of live births # of pregnancies past 20 weeks/5 months Did you have any complications or special conditions with this pregnancy? Do you ever have a hard time chewing or eating certain foods? Listen, ask, and assess for ● Routine oral health care ● Referral needed ● 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 ● Drink to thirst ● Appetite ● Timing of meals ● Meals, snacks, beverages ● Eating pattern ● Frequency ● Eating problems ● Food preparation ● Food likes and dislikes ● Folic acid rich foods ● Pica What would you like to change about your eating? Is there anything you would like to eat more or less of? Do you take any vitamins, minerals, herbs or dietary supplements? Listen, ask, and assess for ● Adequate folic acid intake Other Nutrition Risks Do you have problems with food preparation and/or storage? Listen, ask, and assess for ● Refrigeration ● Cooking equipment ● Adequate food ● Family table ● Safe water

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 In the last 3 months of your pregnancy, 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 In the last 3 months of your pregnancy, how many alcoholic drinks (beer, wine or liquor) did you have in an average week? Drinks/wk Current Alcohol Use Do you currently drink alcohol? If yes, how much and how often? Drinks/Day Drinks/Wk Binge drinking >= 4 drinks within 2 hours 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 are your plans for returning to your pre-pregnancy shape? Listen, ask, and assess for ● Physical activities ● Walking ● Playing with children ● Safe parks ● Access to fitness centers ● Activity frequency ● Food consumption changes

Social Environment What else can I help you with? Listen, ask, and assess for ● Abuse/neglect in the last 6 months ● Limited ability to make appropriate feeding decisions or prepare foods ● Family planning