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Eculogo.gif (2414 bytes)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

Mother Mother Mother
Father Father Father
           
      Household Income    
         

 

Parent(s) Birthdate Information:  Parent(s) and their immediate family members

Month          Day       Year

Mom's Birthdate

   

Mom's Mother Birthdate

   

Mom's Father Birthdate

   

Dad's Birthdate

   

Dad's Mother Birthdate

   

Dad's Father Birthdate

   

 

Parents Sibling(s) Birthdate:  

Month     Year     Month     Year

Mom's 1st sibling

 

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

 

 

Child(ren) Information:

For each child, click on the button if the condition or statement is TRUE.

1st Child 2nd Child

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)

 

Child(ren) Information (continued):

For each child, click on the button if the condition or statement is TRUE.

1st Child 2nd Child

3rd Child

4th Child

5th Child

6th Child

7th Child

8th Child

9th Child

10th Child

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

 

Malformations & Disorders:  CHECK all that apply for each child, otherwise leave blank. 1st Child 2nd Child

3rd Child

4th Child

5th Child

6th Child

7th Child

8th Child

9th Child

10th Child

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

Month         Day        Year

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

   

 

Conception Information:  My child or children were conceived during/by.... 1st Preg 2nd Preg 3rd Preg 4th Preg 5th Preg 6th Preg 7th Preg 8th Preg 9th Preg 10th Preg

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).

 

Choose the BEST answer for each set of multiples that occurred during the appropriate pregnancy.   My multiple's... 1st mult Preg 2nd mult Preg 3rd mult Preg 4th mult Preg 5th mult Preg 6th mult Preg 7th mult Preg 8th mult Preg 9th mult Preg 10th mult Preg

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

 

Multiples characteristics (continued).   My multiple's... 1st mult Preg 2nd mult Preg 3rd mult Preg 4th mult Preg 5th mult Preg 6th mult Preg 7th mult Preg 8th mult Preg 9th mult Preg 10th mult Preg

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

 

Choose the ONE BEST conception history for each  pregnancy 1st Preg 2nd Preg 3rd Preg 4th Preg 5th Preg 6th Preg 7th Preg 8th Preg 9th Preg 10th Preg

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

 

If conception aided with fertility drug...Check ALL drug(s) that apply. 1st Preg 2nd Preg 3rd Preg 4th Preg 5th Preg 6th Preg 7th Preg 8th Preg 9th Preg 10th Preg

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's Birth Family Information:  

Mother of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Mom of Mult Birth

Her Mom

Her Dad Her 1st Sib Her 2nd Sib Her 3rd Sib Her 4th Sib Her 5th Sib Her 6th Sib Her 7th Sib

Single birth

Multiple birth

Male

Female

Adopted?

Left-handed

Right-handed

Amibidexterous

 

Mother's Birth Family Information (continued):  

Mother of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Mom of Mult Birth

Her Mom

Her Dad Her 1st Sib Her 2nd Sib Her 3rd Sib Her 4th Sib Her 5th Sib Her 6th Sib Her 7th Sib

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)

 

Mother's Birth Family Information (continued):  

Mother of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Mom of Mult Birth

Her Mom

Her Dad Her 1st Sib Her 2nd Sib Her 3rd Sib Her 4th Sib Her 5th Sib Her 6th Sib Her 7th Sib

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

 

Mother's Birth Family Information (continued):  

Mother of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Mom of Mult Birth

Her Mom

Her Dad Her 1st Sib Her 2nd Sib Her 3rd Sib Her 4th Sib Her 5th Sib Her 6th Sib Her 7th Sib

Had prof help/hosp for nervous, mental, or emot probs

Cleft lip or palate

Congenital heart defect

Spina bifida (open spine)

Other neural tube defect

Other malformation

Cerebral Palsy

Chromosome disorder

 

Father's Birth Family Information:  

Father of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Dad of Mult Birth

His Mom

His Dad His 1st Sib His 2nd Sib His 3rd Sib His 4th Sib His 5th Sib His 6th Sib His 7th Sib

Single birth

Multiple birth

Male

Female

Adopted?

Left-handed

Right-handed

Amibidexterous

 

Father's Birth Family Information (continued):  

Father of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Dad of Mult Birth

His Mom

His Dad His 1st Sib His 2nd Sib His 3rd Sib His 4th Sib His 5th Sib His 6th Sib His 7th Sib

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)

 

Father's Birth Family Information (continued):  

Father of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Dad of Mult Birth

His Mom

His Dad His 1st Sib His 2nd Sib His 3rd Sib His 4th Sib His 5th Sib His 6th Sib His 7th Sib

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

 

Father's Birth Family Information (continued):  

Father of Multiples... Birth Family

Sib=brother or sister. 

For you and each family member, click on the button if the condition or statement is TRUE.

Dad of Mult Birth

His Mom

His Dad His 1st Sib His 2nd Sib His 3rd Sib His 4th Sib His 5th Sib His 6th Sib His 7th Sib

Had prof help/hosp for nervous, mental, or emot probs

Cleft lip or palate

Congenital heart defect

Spina bifida (open spine)

Other neural tube defect

Other malformation

Cerebral Palsy

Chromosome disorder

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

Laboratory of Behavorial & Developmental Genetics

East Carolina University School of Medicine

Department of Pediatrics

Greenville, NC 27858

EMail:  Dr. Charles E. Boklage

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