Today S Date: Your Name(S)

Preterm Birth Support Network Questionnaire

Thank you for your interest in the Preterm Birth Support Network. The information, support and resources provided by the support network is general information and personal experiences only, and does not necessarily reflect what might happen should your babies be either low birth weight or preterm. If you have any concerns about your own children’s situation, please consult with your children’s physician.

Today’s Date: Your Name(s):

Family Information:

Multiples’ Month/Year of Birth:

E-mail Address: Phone Number:

City/town, Province:

Member of local multiple-birth support Organization: YES NO

Name of Chapter/Organization: MBC Direct Family Member: YES NO

We have other children in addition to our multiples:

Child 1 Age: Child 2 Age: Child 3 Age: Child 4 Age:

Were they born preterm or low birth weight?

Child 1: YES NO Child 2: YES NO Child 3: YES NO Child 4: YES NO

Our Multiple-Birth Children:

We have: Twins Triplets Quadruplets Quintuplets

They were born at:

Baby A: (weeks & days) and Birth weight

Baby B: (weeks & days) and Birth weight

Baby C: (weeks & days) and Birth weight

Baby D: (weeks & days) and Birth weight

Baby E: (weeks & days) and Birth weight

If you suffered the loss of one or more of your multiples through miscarriage, still birth or death in the first weeks of life, please explain here:

Did they spend time in a Neonatal Intensive Care Unit (NICU)? YES NO

If yes, how long?

Baby A: Baby B: Baby C: Baby D: Baby E:

Hospital location of the NICU(s) your babies were in (optional):

Where you given any reason for their early delivery, either due to Mom’s situation or babies’? YES NO

If yes, reason:

At this time, is there any medical diagnosis of a permanent condition (e.g. vision loss, hearing loss, cerebral palsy, asthma, etc.)?

Baby A: Baby B: Baby C: Baby D: Baby E:

Other Information:

Do you feel your prenatal classes properly prepared you for the possibility of a stay for your babies in the NICU?

YES NO Can you explain?

Is there anything about preterm birth and/or the NICU you wish you were aware of beforehand?

Anything else you might like to share?

How is Father/Partner handling the early arrivals?

Can we offer your family any support? YES NO If yes, how?

Would you like to be a possible contact for other parents with preterm or low birth weight babies should there be a request for connection in your area, or with someone with a similar experience? YES NO

If yes, what method of communication would you prefer? Phone or Email

Consent:

We, (Parents Names) agree Multiple Births Canada may use our statistical information to create educational resources and future publication, without names or identifying information. YES NO

Please e-mail completed form to

Thank for your taking the time to complete this Questionnaire, to help MBC determine what information and resources are needed to support families with preterm multiple births.