East Carolina University
Laboratory of Behavorial & Developmental Genetics
Multiple Birth Family Questionnaire
Note: This survey can be viewed using Netscape or Internet Explorer with a screen resolution of 800 x 600 pixels.
Demographics: Families with multiple births (twins, triplets, etc.) View or Print Worksheet
Select the best response from the appropriate pull-down menus
Ethnicity
Occupation
Education Level
Month Day Year
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 --
Parents Sibling(s) Birthdate:
Mom's 1st sibling
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 --
Dad's 1st sibling
Mom's 2nd sibling
Dad's 2nd sibling
Mom's 3rd sibling
Dad's 3rd sibling
Mom's 4th sibling
Dad's 4th sibling
Mom's 5th sibling
Dad's 5th sibling
Mom's 6th sibling
Dad's 6th sibling
Mom's 7th sibling
Dad's 7th sibling
For each child, click on the button if the condition or statement is TRUE.
3rd Child
4th Child
5th Child
6th Child
7th Child
8th Child
9th Child
10th Child
Single Birth
Multiple Birth
Male
Female
Adopted?
Born alive, still alive
Born alive, now deceased
Born dead (still birth)
Premature delivery, less than 32 weeks
Premature delivery, 32-37 weeks
Full-Term birth, 38-40+ weeks
Birth weight less than 3 lbs 5 oz (<1500g)
Birth weight 3 lbs 5 oz to 5 lbs 8 oz (1501g to 2499g)
Birth weight greater than 5 lbs 8 oz (>=2500g)
Right-handed
Left-handed
Amibidexterous
Cleft lip or palate
Congenital heart defect
Open spine or other neural tube defect
Other malformation
Cerebral Palsy
Chromosome disorder
Please provide us with the birthdate of each of your children
Your 1st child
Your 2nd child
Your 3rd child
Your 4th child
Your 5th child
Your 6th child
Your 7th child
Your 8th child
Your 9th child
Your 10th child
current marriage; mom & dad are the biological parents.
previous marriage/partner; mom is biological parent.
previous marriage/partner; dad is biological parent.
current marriage/partner; artifically inseminated.
current marriage/partner; used donor egg cell(s).
body build is VERY MUCH ALIKE
body build is SOMEWHAT ALIKE
body build is DIFFERENT
facial features are VERY MUCH ALIKE
facial features are SOMEWHAT ALIKE
facial features are DIFFERENT
hair color & texture are VERY MUCH ALIKE
hair color & texture are SOMEWHAT ALIKE
hair color & texture are DIFFERENT
eye color is VERY MUCH ALIKE
eye color is SOMEWHAT ALIKE
eye color is DIFFERENT
skin color & texture are VERY MUCH ALIKE
skin color & texture are SOMEWHAT ALIKE
skin color & texture are DIFFERENT
hair & skin smell VERY MUCH ALIKE
hair & skin smell SOMEWHAT ALIKE
hair & skin smell DIFFERENT
Are easily confused by people who DO NOT know them well
Are easily confused EVEN by people who know them well
Conception due to oral contraceptive failure
Conception due to rhythm-method failure
Conception followed separation (2 weeks +) and reunion
Conception aided by fertility drug
Unplanned natural pregnancy
Planned natural pregnancy
None
Clomiphene, Clomid, Serophene
FSH: Fertinex, Follistim, Gonal-F
HCG: Pregnyl, Profasi, Novarel
Progesterone, Crinone
LHRH, GnRH, Lupron
LH+FSH: Pergonal, Humegon, Repronex
Other
Mother of Multiples... Birth Family
For you and each family member, click on the button if the condition or statement is TRUE.
Mom of Mult Birth
Her Mom
Single birth
Multiple birth
Has/had learning disability
Has/had a history of seizures
Has/had speech difficulty
Has/had a drinking problem
Has monozygotic twins or triplets (identical)
Has dizygotic twins or trizygotic triplets (all different)
Has "a pair and a spare" triplets (dizygotic)
Has twins or triplets, zygosity unknown
Wears glasses or contacts
Had prof help/hosp for nervous, mental, or emot probs
Spina bifida (open spine)
Other neural tube defect
Father of Multiples... Birth Family
Dad of Mult Birth
His Mom
Comments:
Thank you so much for taking time out of your busy day to answer this survey. We treasure your cooperation. We will not share your answers with anyone without your permission. We may in the future need to contact you to ask additional questions about your responses, or to request your participation in further studies. Would you please provide us the following information (strictly optional) in case we need to contact you?
Last name: First name:
Street address:
City: State:ZIP code:
Home phone (include area code):
Work phone (include area code):
Mother's Social Security Number:
Father's Social Security Number:
Thanks again for your valuable cooperation and information.
Please scroll down to bottom of page and click the "submit" button.
Sincerely,
Dr. Charles E. Boklage
East Carolina University School of Medicine
Department of Pediatrics
Greenville, NC 27858
EMail: Dr. Charles E. Boklage
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