This form if intended for WOMEN/ COUPLES PLANNING TO HAVE A BABY SOON
(The form is aimed at women, but can also be filled by husbands)
LINES MARKED BY * ARE OPTIONAL

* NAME OF THE MOTHER -
THE MOTHER'S DATE OF BIRTH -
* THE MOTHER'S TIME OF BIRTH -
* THE MOTHER'S PLACE OF BIRTH -
DATES OF OVULATION ON THE PLANNED MONTH -
...AND ON THE FOLLOWING TWO MONTHES -
                                    -
* HUSBAND'S DATE OF BIRTH -

GENERAL AREA WHERE YOU WILL BE STAYING WHEN YOU WILL BE TRYING TO GET PREGNANT
(NY, CA, Holland, Belgium, Brazil, Japan, etc.) -

DO YOU WANT A MALE OR A FEMALE? -