Immune System
Activation of Coagulation
Questionnaire
Date:
Email Address:
Father's Name:
Mother's Name:
Address:
City:
State:
Zip:
Country:
Phone Number:
This section is to be filled out by mother.
During
your pregnancy, did you have any:
High blood pressure
Yes
...
.......
No
..
.......
Don't know
. .
Sugar problem
Yes
...
.......
No
..
.......
Don't know
. .
Excessive weight gain (greater than 35 pounds)
Yes
...
.......
No
..
.......
Don't know
. .
Marked water retention
Yes
...
.......
No
..
.......
Don't know
. .
Pre-ecclampsia or toxemia
Yes
...
.......
No
..
.......
Don't know
. .
Premature labor
Yes
...
.......
No
..
.......
Don't know
. .
Bleeding problems
Yes
...
.......
No
..
.......
Don't know
. .
Before
and
after
pregnancy, did you have any:
Heavy menses with blood clots
Yes
...
.......
No
..
.......
Don't know
..
Migraine headaches
Yes
...
.......
No
..
.......
Don't know
. .
High blood pressure
Yes
...
.......
No
..
.......
Don't know
. .
Chronic fatigue
Yes
...
.......
No
..
.......
Don't know
. .
Depression
Yes
...
.......
No
..
.......
Don't know
. .
Chronically sore or painful muscles or joints
Yes
...
.......
No
..
.......
Don't know
. .
Inflammatory bowel disease
Yes
...
.......
No
..
.......
Don't know
. .
Chronic or common abdominal pain
Yes
...
.......
No
..
.......
Don't know
. .
Chronic headaches
Yes
...
.......
No
..
.......
Don't know
. .
Obsessive or compulsive problems
Yes
...
.......
No
..
.......
Don't know
. .
Infertility problems
Yes
...
.......
No
..
.......
Don't know
. .
Do your
maternal
relatives
have any history of:
Problem pregnancies or getting pregnant
Yes
...
.......
No
..
.......
Don't know
. .
Early heart disease
Yes
...
.......
No
..
.......
Don't know
. .
Heart attacks
Yes
...
.......
No
..
.......
Don't know
. .
Strokes
Yes
...
.......
No
..
.......
Don't know
. .
Cancers
Yes
...
.......
No
..
.......
Don't know
. .
Migraines
Yes
...
.......
No
..
.......
Don't know
. .
Inflammatory bowel disease
Yes
...
.......
No
..
.......
Don't know
. .
Autoimmune problems
Yes
...
.......
No
..
.......
Don't know
. .
Diabetes
Yes
...
.......
No
..
.......
Don't know
. .
Cerebral palsy
Yes
...
.......
No
..
.......
Don't know
. .
This section is to be filled out by father.
Do
you
have any history of:
High blood pressure
Yes
...
.......
No
..
.......
Don't know
. .
Heart disease
Yes
...
.......
No
..
.......
Don't know
. .
Strokes
Yes
...
.......
No
..
.......
Don't know
. .
Migraines
Yes
...
.......
No
..
.......
Don't know
. .
Abdominal pain
Yes
...
.......
No
..
.......
Don't know
. .
Muscle pain all the time
Yes
...
.......
No
..
.......
Don't know
. .
Persistent joint pain
Yes
...
.......
No
..
.......
Don't know
. .
Autoimmune disorders
Yes
...
.......
No
..
.......
Don't know
. .
Do your
paternal
relatives
have any history of:
High blood pressure
Yes
...
.......
No
..
.......
Don't know
. .
Heart disease
Yes
...
.......
No
..
.......
Don't know
. .
Strokes
Yes
...
.......
No
..
.......
Don't know
. .
Migraines
Yes
...
.......
No
..
.......
Don't know
. .
Abdominal pain
Yes
...
.......
No
..
.......
Don't know
. .
Muscle pain all the time
Yes
...
.......
No
..
.......
Don't know
. .
Persistent joint pain
Yes
...
.......
No
..
.......
Don't know
. .
Autoimmune disorders
Yes
...
.......
No
..
.......
Don't know
. .
Problem pregnancies
Yes
...
.......
No
..
.......
Don't know
. .
Infertility problems
Yes
...
.......
No
..
.......
Don't know
. .
Heart attacks
Yes
...
.......
No
..
.......
Don't know
. .
Strokes
Yes
...
.......
No
..
.......
Don't know
. .
Cancers
Yes
...
.......
No
..
.......
Don't know
. .
Inflammatory bowel disease
Yes
...
.......
No
..
.......
Don't know
. .
Diabetes
Yes
...
.......
No
..
.......
Don't know
. .
Cerebral palsy
Yes
...
.......
No
..
.......
Don't know
. .
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