This form if intended for WOMEN WHO ARE ALREADY PREGNANT
(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 -
DATE AND TIME (as accurate as possible) IN WHICH YOU GOT PREGNANT -
* HUSBAND'S DATE OF BIRTH -
GENERAL AREA WHERE YOU BECAME PREGNANT
(NY, CA, Holland, Belgium, Brazil, Japan, etc.) -