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Additional information
Please answer the following - statistical purpose
Date of last birth
Number of gestation weeks
Hospital of birth
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Hôpital Maisonneuve-Rosemont
Hôpital de Montréal pour Enfants
Hôpital Général Juif
CHU Québec
CHU Sherbrooke
CHU Ste-Justine
CH Anna-Laberge
CH Charles-Lemoyne
CH Chicoutimi
CH du Suroît
CH East Ottawa (CHEO)
CH Gatineau
CH Granby
CH Haut-Richelieu
CH Hôtel Dieu de Lévis
CH Hôtel Dieu de Victoriaville
CH Joliette
CH La Sarre
CH Lanaudière
CH Lasalle
CH Lévis
CH Matane
CH Pierre-Boucher
CH Pierre-Legardeur
CH Rimouski
CH Rivière-du-loup
CH Rouyn-Noranda
CH St-Eustache
CH St-François d'Assise
CH St-Hyacinthe
CH ST-Jean
CH St-Jérôme
CH St-Luc
CH St-Mary's
CH Trois Rivières
CH Val d'Or
CH Valleyfield
Cité de la Santé
HGOttawa
Secondary Hospital Center
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Hôpital de Montréal pour Enfants
Hôpital Maisonneuve-Rosemont
Hôpital Général Juif
CHU Québec
CHU Sherbrooke
CHU Ste-Justine
CH Anna-Laberge
CH Charles-Lemoyne
CH Chicoutimi
CH du Suroît
CH East Ottawa (CHEO)
CH Gatineau
CH Granby
CH Haut-Richelieu
CH Hôtel Dieu de Lévis
CH Hôtel Dieu de Victoriaville
CH Joliette
CH La Sarre
CH Lanaudière
CH Lasalle
CH Lévis
CH Matane
CH Pierre-Boucher
CH Pierre-Legardeur
CH Rimouski
CH Rivière-du-loup
CH Rouyn-Noranda
CH St-Eustache
CH St-François d'Assise
CH St-Hyacinthe
CH ST-Jean
CH St-Jérôme
CH St-Luc
CH St-Mary's
CH Trois Rivières
CH Val d'Or
CH Valleyfield
Cité de la Santé
HGOttawa
Number of children in the last pregnancy
Have you lost a premature infant
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yes
no
How many children 6 years or younger, do you have?
What is your family income?
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Less than $35 000
$35 000 to $50 000
$50 000 to $100 000
$100 000 to $200 000
$200 000 and above
Have your family immigrated less than 5 years ago?
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yes
no
Are you a single parent?
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yes
no
Are you an Aboriginal?
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yes
no
Please select the language spoken at home
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French
English
Other
Please select the mother's age group during childbirth
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0 to 19
20 to 25
26 to 30
31 to 35
35 and +
Please select your completed study level
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Primary School
High School
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