Prenatal Questionnaire - Tufts Health Plan

19. Have you used any of the following during this pregnancy?❏ No ❏ Alcohol ❏ Tobacco ❏ Street Drugs, such as CocainePlease indicate any specific questions or concerns that we may address for you._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Additional information you would like us to know.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please return your completed prenatal questionnaire to Tufts Health Plan.By Mail: Tufts Health Plan By Fax: (617) 972-9417Attn: Maternity Program Manager, Health Programs705 Mt. Auburn Street, Watertown, MA 02472-1508If you have a benefit or payment question, please contact Tufts Health Plan Member Services,at the number located on the back of your Identification Card.11/13