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Law Offices of Sybil Shainwald
A Professional Corporation
A Professional Corporation
Page 3
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27. Your parents' address when your mother was pregnant with you: __________________________________________________________ __________________________________________________________ 28. The inclusive dates of your mother's pregnancy with you, and whether or not full term: ___________________________________________________________ ___________________________________________________________ 29. During what months of her pregnancy with you was your mother given DES (starting with her last menstrual period)? Please place a check by the appropriate month(s): ___ 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 ___ 8 ___ 9 30. How do you know that your mother took DES during her pregnancy with you? ( You may check more than one.) ____ Your mother's medical records have been checked and show that she took DES. ____ Your mother remembered for certain that she took DES during her pregnancy. ____ Your mother thought that she took DES but was not sure. ____ A physician or some other person remembered that your mother took DES. ____ A physician examined you and told you that your mother probably took DES. ____ Other source of information, please specify: ___________________________________________________________ ___________________________________________________________ 31. Name and address of your mother's obstetrician (the doctor who delivered you): ___________________________________________________________ ___________________________________________________________ 32. Please check below the reason(s) for which DES was given to your mother during her pregnancy with you: ____ threatened miscarriage ____ bleeding during pregnancy ____ previous miscarriage(s) ____ infertility problems ____ diabetes ____ unknown ____ other, please specify: __________________________________________________________ __________________________________________________________ |
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