Professional Documents
Culture Documents
Lab 1
Lab 1
15. Were any of these still births or late term miscarriages? G Yes G No G I don’t care to say
16. Were any of these early-term miscarriages? G Yes G No G I don’t care to say
17. How many children have you had? [ __ ] 18. How many of your children are still alive? [ _ ]
20. Did you or do you use any forms of contraception? G Yes G No G I don’t care to say
Parents
Mother
Father
Children
Father
Son Daughter
Son Daughter
Son Daughter
Father
Son Daughter
Son Daughter
Son Daughter
Father
Son Daughter
Son Daughter
Son Daughter
Father
Son Daughter
Son Daughter
*Life stage age at death: A= breastfeeding, NOT walking; B= Breastfeeding & walking C= Juvenile D= Menstruating unmarried girl E= teenage boy F= married no
child G= married with unmarried children H= married with married children; M=miscarriage or still birth
Brother & Sisters
If individual is deceased
Relation Name Birth Yr Alive? Life Age Cause of death Page Notes
(circle one) Yes stage at at reference
/No death* death
Bro Sis Ma:
G full sib G½ sib
Fa:
Bro Sis Ma:
G full sib G½ sib
Fa:
Bro Sis Ma:
G full sib G½ sib
Fa:
Bro Sis Ma:
G full sib G½ sib
Fa:
Bro Sis Ma:
G full sib G½ sib
Fa:
Bro Sis Ma:
G full sib G½ sib
Fa:
Bro Sis Ma:
G full sib G½ sib
Fa:
*Life stage at death: A= breastfeeding, NOT walking; B= Breastfeeding & walking C= Juvenile D= Menstruating unmarried girl E= teenage boy F=
married no child G= married with unmarried children H= married with married children; M=miscarriage or still birth
NOTES: