Please tell us about you and who will be attending with you:

Date of Class:

Your Age:

40 Week Due Date: / /

Your First Name:

Last Name:

Address:

City:

State: AL GA

ZIP

Home Telephone:

Work Telephone:

FAX:

Your E-mail Address:

Your Occupation:

 

Name of Person Attending With You:

Relationship: Select One Husband Fiancee Friend Mother Mother-in-Law Father Father-in-Law Doula Other

Occupation:

 

Other Children Living with You and Ages:

Name of your primary obstetric care provider: Select MD DO Midwife Other

Hospital for delivery of your babies:

Are you also seeing any specialists? Perinatologist Dietitian

What kind of multiples are you having?

Select Twins Triplets Quadruplets (Other) Other:

Do you know if they are: Select Identical Fraternal Triplets 2 Identical 1 Fraternal Unknown

________________________________________________________

Your Pregnancy History:

Total Number of Pregnancies (including this one) 1 2 3 4 5

How many full-term births Select 0 1 2 3 4 5

How many were premature? Select 0 1 2 3 4 5

Born at how many weeks? Select 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Reason for Premature Delivery

Miscarriages/Abortions Select 0 1 2 3 4 5 At how many weeks? Select 4 5 6 7 8 9 10 11 12 13 14

Have you had a Vaginal Delivery? C-Section? VBAC?

________________________________________________________

How were your multiples conceived? Check all that apply.

Spontaneous

Fertility Medications        What type?

Insemination

GIFT

IVF

ICSI

Cryopreserved ET

Other

Have you had a pregnancy reduction procedure? Select No Yes For how many? Select 1 2 3 4 5

________________________________________________________

Do you have any current medical problems? Please describe:

Do you have any current pregnancy complications? Please describe:

What has your doctor told you to expect with this pregnancy?

________________________________________________________

Who will be your babies’ Pediatrician?

What are your plans for feeding your babies? Check all that apply:

Fully Breastfeed

Partial Breastfeed/Bottle Feed

Fully Bottle Feed

What are your concerns for this pregnancy? Please specify.

Pregnancy complications

Nutrition

Bedrest

Labor and Birth

Finances

Other Children

Lack of Support / Help at Home

Ability to Care for Babies

Breastfeeding

History of Depression

Other

What specific information would you like to learn from this course?

What would the babies’ father like to learn?

Other questions, concerns, needs:

I (we) desire to participate in the Marvelous Multiples® Prenatal Education Course. I (we) understand that the purpose of the Marvelous Multiples® Prenatal Education Course is to present information about multiple pregnancy and birth. I (we) understand that this information is not a substitute for professional medical care. Further, I (we) agree that it is my (our) responsibility to consult with my (our) personal physician or health care provider before acting upon any information or beginning any procedure or care plan presented in the course and to clarify any questions or concerns. In consideration of my (our) participation in the Marvelous Multiples® Prenatal Education Course, I (we) do hereby release, indemnify and hold harmless Marvelous Multiples, Inc., together with its directors, officers, employees, volunteers, agents and affiliates from any liability, loss, claim, causes, damage and expense that may arise from or relate to my (our) pregnancy, birth or related care. I (we) agree that my (our) attendance in this course and the use of the course materials does not guarantee any outcome relating to my (our) pregnancy and that I (we) have received no representations or assurances as to any particular outcome from attending the course.

(Typing in your names on this electronic form is equivalent to your written signature).

Signed (mother)

Signed (father, or other attendee)

Date: