How many children do you have?

Please provide the following for each child:

Are any of your children with cleft adopted? Yes No

If yes, which child? (Name)

Did you have any miscarriages? Yes No

If yes, how many?

Are you planning on having another child? Yes No

If Yes, when?

If No, why?

If you have more than 1 child with cleft, did you take vitamins and/or Folic Acid during the other pregnancy? Yes No

If YES, when did you begin and for how long?

At which Craniofacial Center is/was the child with cleft treated?

Name of the Physician(s) who treated the child:

Do any of your relatives have a cleft? Yes No

If YES, please specify their relation to you, name and date of birth:

Do any of your relatives have other birth defects? Yes No

If YES, please specify their relation to you, name and date of birth:

Information regarding your pregnancy with the child with cleft:
(Please provide information regarding the period before and during the first trimester of the pregnancy)

Was the pregnancy planned? Yes No

At what point did you begin prenatal care?

Did you take vitamins and/or Folic Acid during this pregnancy? Yes No

If YES, when did you begin and for how long?

Did you take other prescription or over the counter medications? Yes No

Did you suffer from morning sickness? Yes No

If YES, how often and for how long?

Did you take any medication for the sickness? Yes No

If YES, what medication?

Describe the area in which you lived: Rural Suburban City Inner City Other

What sort of water did you drink? Tap Water Bottled Water Well Water Other

What was your occupation?

How often did you use the computer? (#hrs/wk)

Were you exposed to any chemicals in your home/work environment? Yes No

If YES, what sort of chemicals? (Pesticides, gases, etc.)

Thank you for your time and generosity. We appreciate your help in our research, as we continue our efforts to understand the etiology of cleft and craniofacial anomalies.

Please send this questionnaire by clicking on the "Submit" button after you have finished.

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