Your birth history

When were you born? I was born 11-20 days before my due date. I was born 7-10 days before my due date. I was born 3-6 days before my due date. I was born 0-2 days before my due date. I was born after my due date. I was a premature baby. Unsure.

I was born in the morning afternoon evening middle of the night Unsure.

How much did you weigh when you were born? unsure 5 pounds or less 5 1/2 pounds 6 pounds 6 1/2 pounds 7 pounds 7 1/2 pounds 8 pounds 8 1/2 pounds 9 pounds 9 1/2 pounds 10 pounds or more

My mother's labor was unsure under 2 hours 2-3 hours 4-5 hours 6-7 hours 8-9 hours 10-12 hours 13-15 hours 16-18 hours 18-20 hours 20-24 hours 25 hours or more

Your husband/partner's birth history

When were you born? He was born 11-20 days before his due date. He was born 7-10 days before his due date. He was born 3-6 days before his due date. He was born 0-2 days before his due date. He was born after his due date. He was a premature baby. Unsure.

He was born in the morning afternoon evening middle of the night Unsure.

How much did he weigh when he was born? unsure 5 pounds or less 5 1/2 pounds 6 pounds 6 1/2 pounds 7 pounds 7 1/2 pounds 8 pounds 8 1/2 pounds 9 pounds 9 1/2 pounds 10 pounds or more

My husband/partner's mother's labor was unsure under 2 hours 2-3 hours 4-5 hours 6-7 hours 8-9 hours 10-12 hours 13-15 hours 16-18 hours 18-20 hours 20-24 hours 25 hours or more

Previous Children's History

I have given birth to 0, I have not had any children 1 2 3 4 5 or more number of children.

Only fill out the questions below for the number of children applicable to you. If you have not had any children skip this section.

If you have had more than 3 children enter your last 3 children's information in.

Child number 1

Child number 1 was born? My child was born 11-20 days before his or her due date. My child was born 7-10 days before his or her due date. My child was born 3-6 days before his or her due date. My child was born 0-2 days before his or her due date. My child was born after his or her due date. My child was a premature baby. Unsure.

Child number 1 was born in the morning afternoon evening middle of the night Unsure.

Child number 1 weighed when s/he was born? 5 pounds or less 5 1/2 pounds 6 pounds 6 1/2 pounds 7 pounds 7 1/2 pounds 8 pounds 8 1/2 pounds 9 pounds 9 1/2 pounds 10 pounds or more

My labor was under 2 hours 2-3 hours 4-5 hours 6-7 hours 8-9 hours 10-12 hours 13-15 hours 16-18 hours 18-20 hours 20-24 hours 25 hours or more

Child number 2

Child number 2 was born? My child was born 11-20 days before his or her due date. My child was born 7-10 days before his or her due date. My child was born 3-6 days before his or her due date. My child was born 0-2 days before his or her due date. My child was born after his or her due date. My child was a premature baby. Unsure.

Child number 2 was born in the morning afternoon evening middle of the night Unsure.

Child number 2 weighed when s/he was born? 5 pounds or less 5 1/2 pounds 6 pounds 6 1/2 pounds 7 pounds 7 1/2 pounds 8 pounds 8 1/2 pounds 9 pounds 9 1/2 pounds 10 pounds or more

My labor was under 2 hours 2-3 hours 4-5 hours 6-7 hours 8-9 hours 10-12 hours 13-15 hours 16-18 hours 18-20 hours 20-24 hours 25 hours or more

Child number 3

Child number 3 was born? My child was born 11-20 days before his or her due date. My child was born 7-10 days before his or her due date. My child was born 3-6 days before his or her due date. My child was born 0-2 days before his or her due date. My child was born after his or her due date. My child was a premature baby. Unsure.

Child number 3 was born in the morning afternoon evening middle of the night Unsure.

Child number 3 weighed when s/he was born? 5 pounds or less 5 1/2 pounds 6 pounds 6 1/2 pounds 7 pounds 7 1/2 pounds 8 pounds 8 1/2 pounds 9 pounds 9 1/2 pounds 10 pounds or more

My labor was under 2 hours 2-3 hours 4-5 hours 6-7 hours 8-9 hours 10-12 hours 13-15 hours 16-18 hours 18-20 hours 20-24 hours 25 hours or more

Medical History

Do you or have you had gestational diabetes? yes no

Do you or have you had preterm labor? yes no

Do you or have you had high blood pressure? yes no

Have you had a previous cesarian section? yes no

Has your labor been induced in your previous pregnancies before your due date?
yes no

Has your labor been induced in your previous pregnancies on or after your due date?
yes no