Parental Demographics and Birthdate Information Ethnicity of Parents Education Level Father Mother Mother Father ( ) White ( ) ( ) None ( ) ( ) Black ( ) ( ) 1-11 ( ) ( ) Hispanic ( ) ( ) HS Grad ( ) ( ) Oriental ( ) ( ) Some College ( ) ( ) Am Indian( ) ( ) College Grad ( ) ( ) Other ( ) ( ) Graduate Deg ( ) Occupation Father Mother Household Income ( ) Homemaker ( ) ( ) Less than 20,000 ( ) Prof.,Tech.,Educators ( ) ( ) $20,001-$35,000 ( ) Sales, Clerical ( ) ( ) $35,001-$50,000 ( ) Skilled Crafts & Trades ( ) ( ) $50,001-$75,000 ( ) Production Work ( ) ( ) Over $75,000 ( ) Exec., Admin., Mngr'l ( ) ( ) Choose not to disclose ( ) Service Work ( ) MM / DD / YY Mother's Birthdate ____/____/____ Mother's Mother Birthdate ____/____/____ Mother's Father Birthdate ____/____/____ Father's Birthdate ____/____/____ Father's Mother Birthdate ____/____/____ Father's Father Birthdate ____/____/____ MM / DD / YY Mother's 1st Sibling Birthdate ____/____/____ Mother's 2nd Sibling Birthdate ____/____/____ Mother's 3rd Sibling Birthdate ____/____/____ Mother's 4th Sibling Birthdate ____/____/____ Mother's 5th Sibling Birthdate ____/____/____ Mother's 6th Sibling Birthdate ____/____/____ Mother's 7th Sibling Birthdate ____/____/____ MM / DD / YY Father's 1st Sibling Birthdate ____/____/____ Father's 2nd Sibling Birthdate ____/____/____ Father's 3rd Sibling Birthdate ____/____/____ Father's 4th Sibling Birthdate ____/____/____ Father's 5th Sibling Birthdate ____/____/____ Father's 6th Sibling Birthdate ____/____/____ Father's 7th Sibling Birthdate ____/____/____ Child(ren) Characteristics and Birth Information 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Child Child Child Child Child Child Child Child Child Child Single Birth ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Multiple Birth ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Male ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Female ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Adopted? ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Born alive, still alive ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Born alive, now deceased ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Born dead (still birth) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Premature delivery, < 32ks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Premature delivery, 32-3wks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Full-term birth, 38-40+ s ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight < 3lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight, 3lbs 5oz to 5lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight > 5lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Right-handed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Left-handed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Amibidextrous ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Cleft lip or palate ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Congenital heart defect ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Open spine or other neural Tube defect ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Other malformation ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Cerebral Palsy ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Chromosome disorder ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) MM / DD / YY 1st Child's Birthdate ____/____/____ 2nd Child's Birthdate ____/____/____ 3rd Child's Birthdate ____/____/____ 4th Child's Birthdate ____/____/____ 5th Child's Birthdate ____/____/____ 6th Child's Birthdate ____/____/____ 7th Child's Birthdate ____/____/____ 8th Child's Birthdate ____/____/____ 9th Child's Birthdate ____/____/____ 10th Child's Birthdate ____/____/____ Pregnancy and Characteristics of Multiples Information 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Preg Preg Preg Preg Preg Preg Preg Preg Preg Preg Most recent marriage; mom & Dad are the biological parents ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Previous partner; mom is Biological parent ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Previous partner; dad is Biological parent ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Current partner; artifically inseminated ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Current partner; used donor Egg cell(s) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) My Multiples... 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 very much alike ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Hair color/texture 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 very much alike ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Skin color/texture somewhat alike ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Skin color/texture are different ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Hair & skin smell very much alike ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Hair & skin smell somewhat alike ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Hair & skin smell different ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Pregnancy and Characteristics of Multiples Information (cont) 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Preg Preg Preg Preg Preg Preg Preg Preg Preg Preg My Multiples... Are easily confused by people who DO NOT know them well ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Are easily confused EVEN by people who know them well ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Conception Information Choose ONE conception history for each pregnancy Conception due to oral contraceptive failure ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Conception due to rhythm method failure ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Conception following separation (2wks +) and reunion ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Conception aided by Fertility drug ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Unplanned natural pregnancy ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Planned natural pregnancy ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) If Conception Aided by Fertiltiy Drug, mark all that apply 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 Sib = brother or sister Mom Her Her 1st 2nd 3rd 4th 5th 6th 7th of Mom Dad Sib Sib Sib Sib Sib Sib Sib Mult Single Birth ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Multiple Birth ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Male ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Female ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Adopted? ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Right-handed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Left-handed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Amibidexterous ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Premature delivery, < 32 wks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Premature delivery, 32-37 wks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Full-term birth, 38-40+ wks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight < 3lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight, 3lbs 5oz to 5lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight > 5lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had learning disability ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had history of seizures ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had speech difficulty ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had drinking problem ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has monozygotic twins or triplets (identical) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) has dizygotic twins or triplets (fraternal - all different) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) has "a pair and a spare" triplets (dizygotic) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) has twins or triplets, zygosity unknown ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) wears glasses or contacts ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) had professional help for nervous, mental, or emotional problems ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mother's Birth Family (cont) Sib = brother or sister Mom Her Her 1st 2nd 3rd 4th 5th 6th 7th of Mom Dad Sib Sib Sib Sib Sib Sib Sib Mult 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 Sib = brother or sister Dad His His 1st 2nd 3rd 4th 5th 6th 7th of Mom Dad Sib Sib Sib Sib Sib Sib Sib Mult Single Birth ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Multiple Birth ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Male ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Female ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Adopted? ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Right-handed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Left-handed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Amibidexterous ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Premature delivery, < 32 wks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Premature delivery, 32-37 wks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Full-term birth, 38-40+ wks ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight < 3lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight, 3lbs 5oz to 5lbs 8oz( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Birth weight > 5lbs 8oz ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had learning disability ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had history of seizures ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had speech difficulty ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has/had drinking problem ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Has monozygotic twins/triplets (identical) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) has dizygotic twins or triplets (fraternal - all different) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Father's Birth Family (cont) Sib = brother or sister Dad His His 1st 2nd 3rd 4th 5th 6th 7th of Mom Dad Sib Sib Sib Sib Sib Sib Sib Mult has "a pair and a spare" triplets (dizygotic) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) has twins or triplets, zygosity unknown ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) wears glasses or contacts ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) had professional help for nervous, mental, or emotional problems ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Cleft lip or palate ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Congenital heart defect ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Spina bifida (open spine) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Other neural tube defect ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Other malformation ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Cerebral Palsy ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Chromosome disorder ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )