The following information would be helpful in IOMOTC's effort to compile a databank of general information to help other mothers of multiples with similar problems and possibly for research purposes. No information will be given to either members or research projects without your consent. Any statistics published by us will not include names of individuals. Please complete as much of this questionnaire as possible. Thank you for your time and contribution. This form is on a secure site, so only our VP of Research can view your data.
First name
*
Last name
*
Phone number
Street address
City
State
*
- - Choose One - -
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Email address
Name of local club
*
Are you willing to participate in a research project if asked?
*
No
Yes
Are you willing to talk to other MOMs with similar issues?
*
Yes
No
How many children do you have?
*
How many sets of multiples do you have? (please use additional multiples form for other set)
*
Either parent a multiple?
*
No
Yes-mother
Yes-father
Do multiples run in the family?
*
No
Yes-mother's side
Yes-father's side
Yes-siblings
Member's medical conditions:
Mother
Sleep apnea
Heart disease
Asthma
Allergies
Diabetes
Sight problems
Deafness
Respiratory diseases
Speech problems
Learning difficulties
Cancer
Arthritis
Depression
Post Partum Depression
Other medical issues not listed
Father
Sleep apnea
Heart disease
Asthma
Allergies
Diabetes
Sight problems
Deafness
Respiratory diseases
Speech problems
Learning difficulties
Cancer
Arthritis
Depression
Other medical issues not listed
Are you:
*
Birth parent
Adoptive parent
Step parent
Other legal guardian
How did you conceive?
*
Natural
IVF
IUI
Fertility drugs
Used surrogate
Donor eggs
Donor sperm
Any complications?
*
How old were you when you conceived?
How many weeks were you when you found out you were having multiples?
How did you deliver?
*
Vaginal
C-section
Both
Any complications before/during/after delivery?
Was labor induced?
*
Yes
No
Did you suffer from Post Pardum Depression? If yes, for how long?
Did you breastfeed? If yes, how long?
*
Multiple type:
*
Twins
Triplets
Quads
More
Zygosity (check all that apply for HOM)
*
Fraternal
Identical confirmed by doctor
Identical confirmed by DNA test
Not sure
If school aged, how long did you keep them together, if at all?
Date of multiples birth (mm/dd/yyyy
*
At what week were multiples born?
*
1st Multiple (baby A)
Name
*
Sex
*
Male
Female
Weight
*
Time
*
Handedness
*
Right
Left
Both
Too soon to tell
Presentation
Head-first
Breech
Crosswise
How long did baby stay in hospital?
*
Medical conditions:
Apnea Monitoring
Cerebral Palsy
Heart disease
Asthma
Allergies
Downs Syndrome
Diabetes
Vision loss or difficulty
Deafness or hearing loss
Respiratory diseases
Speech and language delays
Development delays
Jaundice
Spina Bifida
Genetic Disorder
Mental Health concerns
Other medical issues not listed
2nd Multiple (baby B)
Name
*
Sex
*
Male
Female
Weight
*
Time
*
Handedness
*
Right
Left
Both
Too soon to tell
Presentation
Head-first
Breech
Crosswise
How long did baby stay in hospital?
*
Medical conditions:
Apnea Monitoring
Cerebral Palsy
Heart disease
Asthma
Allergies
Downs Syndrome
Diabetes
Vision loss or difficulty
Deafness or hearing loss
Respiratory diseases
Speech and language delays
Development delays
Jaundice
Spina Bifida
Genetic Disorder
Mental Health concerns
Other medical issues not listed
3rd Multiple (baby C)
Name
Sex
Male
Female
Weight
Time
Handedness
Right
Left
Both
Too soon to tell
Presentation
Head-first
Breech
Crosswise
How long did baby stay in hospital?
Medical conditions:
Apnea Monitoring
Cerebral Palsy
Heart disease
Asthma
Allergies
Downs Syndrome
Diabetes
Vision loss or difficulty
Deafness or hearing loss
Respiratory diseases
Speech and language delays
Development delays
Jaundice
Spina Bifida
Genetic Disorder
Mental Health concerns
Other medical issues not listed
4th Multiple (baby D)
Name
Sex
Male
Female
Weight
Time
Handedness
Right
Left
Both
Too soon to tell
Presentation
Head-first
Breech
Crosswise
How long did baby stay in hospital?
Medical conditions:
Apnea Monitoring
Cerebral Palsy
Heart disease
Asthma
Allergies
Downs Syndrome
Diabetes
Vision loss or difficulty
Deafness or hearing loss
Respiratory diseases
Speech and language delays
Development delays
Jaundice
Spina Bifida
Genetic Disorder
Mental Health concerns
Other medical issues not listed