Date
     	
MOTHER’S INFORMATION	Last name (including former last names)
     	
	First names
     	Identity code
     	
	Address
     	
	Telephone (work, home, mobile)
     	E-mail address
     	Mother tongue
     	
	Family situation (married, living together, other)
     	Occupation
     	Employer
     	
	Born in (town or municipality)
     	Living in (town or municipality)
     	Church parish/civil register
     	
SPOUSE’S/
CHILD’S FATHER’S INFORMATION 	Name
     	Date of birth
     	
	Father’s phone number and address
     	Occupation
     	
	 Living together with the mother		
Earlier 
pregnancies
and births	

Date of delivery	Prematurely ended pregnancy, ended in week	

Sex: Boy/
Girl	

Living (L)/
Dead (D)	

Birth weight, 
grams	

Course of the pregnancy, delivery and postnatal period	How many weeks did the pregnancy last?	How many hours did the delivery last?	How many months did you breast-feed?	

Delivery took place in 	
	     	     	     	  	     	     	     	     	  	     	
	     	     	     	  	     	     	     	     	  	     	
	     	     	     	  	     	     	     	     	  	     	
	     	     	     	  	     	     	     	     	  	     	
	     	     	     	  	     	     	     	     	  	     	
	     	     	     	  	     	     	     	     	  	     	
	     	     	     	  	     	     	     	     	  	     	
Parents’ significant illnesses
M = mother
P = father	M	P		M 	P		M		FEMALE GENITAL CONDITIONS	

 

 	1 diabetes
2 high blood pressure
3 allergy
4 kidney condition 
5 heart condition
6 liver condition	 

 

 
 
 	7 lung disease
8 epilepsy
9 neurological disease
10 mental illness
11 birth defects 

12 disability/sensory problem
13 genital herpes
14 other	

	15 urinary tract condition
16 thyroid condition
17 rheumatoid condition
18 surgery
19 chickenpox
20 rubella
21 blood transfusion	M	
22 surgery
23 tumours
24 infertility
25 hormone therapies
26 sexually transmitted
     diseases
27 other	

		
								
	More information on the mother’s illnesses and places where treated
     	
	Medication
     	
	Significant illnesses in the family (malformations, hereditary diseases)
     	
Will the father be present at the delivery?
     	

Mother’s information and the current status of her pregnancy	Last menstrual period, date
     	Menstrual cycle
Regular    Irregular	Latest cervical (Pap) smear, date
     	
	Height (cm) and weight (kg) before pregnancy	What type of contraception was used before pregnancy?	
	
      cm	
      kg	     	Date of stopping contraception
     	
	Preceding infertility treatments, please describe
     	
Pregnancy tests	Date when performed
     	
	Date when performed
     	
	Date when performed
     	
Health habits
M = mother
P = father	Before pregnancy	During pregnancy	

Sports	
	
Smoking	
Alcohol	
Used/tried drugs	
Smoking	
Alcohol	
Used/tried drugs		
	M    /  P
  No
  Yes
Number/day
     	M    /  P
  No
  Yes
Amount/week
     	M    /  P
  No
  Yes
	M    /  P
  No
  Yes
Number/day
     	M    /  P
  No
  Yes
Amount/week
     	M    /  P
  No
  Yes
	     	
	Are you exposed to tobacco smoke on a daily basis? 
 No                   Yes                  	Are you exposed to tobacco smoke on a daily basis? 
 No                   Yes                  		
Food, diet	
 Normal        Special diet, please describe