Section 1: General and zygosity question
     
  1. What type of twin are you ?
Identical Non-Identical
 
  2. How old are you (year)?
 
  3. To which race do you belong to?
 
  4. Who is filling up this questionnaire?
 
  5. Were the twins living with each other during childhood?
Yes No
 
  6. Are the twins’ look  like two peas in a pot?
Yes No Don't Know
 
  7. Did relatives, siblings and friends have difficulty recognizing twins?
Yes No Don't Know
 
  8. Were twins wearing identification marks during childhood?
Yes No Don't Know
     
 
     
  Section 2: Contact Information
     
Twin 1 Twin 2
Name:*
IC Number:*
Postal Address:*
 
Home Tel:*
Hand phone:*
E-mail:*
Name:*
IC Number:*
Postal Address:*
 
Home Tel:*
Hand phone:*
E-mail:*
     
 
     
  Section 3: Socio-demographic and reproductive health questions:
     
No. Description

Twin 1  

Twin 2  

1. Gender:*
2. Education:*
3. Occupation:*
4. Marriage status:*
5. Birth Weight (grams):*
6. Gestational age:*
7. Breast fed:*
Yes No
Yes No
8. Blood Group: *
9. RH:*
Negative Positive
Negative Positive
10. Congenital abnormality:*
Yes No
Yes No
11. Vaccination:*
Yes No
Yes No
12. Age of menarche:
13. Menstruation:
Yes No
Yes No
14. Duration (days):
15. Interval (days):
16. Amount:
Low Normal High
Low Normal High
17. PMS:
Yes No
Yes No
18. Age of Marriage:*
19. Age of First Pregnancy:
20.  
G: P: Ab:
Ch: Boy: Girl:
G: P: Ab:
Ch: Boy: Girl:
21. Last Delivery:
Normal C/S AS
Normal C/S AS
22. Prenatal Care:
Hospital Clinic
Private None
Hospital Clinic
Private None
23. Postnatal Care:
Hospital Clinic    
Private Home None
Hospital Clinic    
Private Home None
24. Brest Feeding:
Yes No
Yes No
25. Gynecological problem:
Yes No
Yes No
26. Irregular menstruation:
Yes No
Yes No
27. Amenorrhea:
Yes No
Yes No
28. Acne:*
Yes No
Yes No
29. Hirsutism:*
Yes No
Yes No
30. Baldness:*
Yes No
Yes No
31. Weight / Height:
/
/
32. Infertility:*
Yes No
Yes No
33. Family planning:
Yes No
Yes No
34. Cancer:*
Yes No
Yes No
35. Pap smear:
Yes No
Yes No
36. Age of menopause:
37. Hot flushes:*
Yes No
Yes No
38. Sweating:*
Yes No
Yes No
39. Pain in bones and joints:*
Yes No
Yes No
40. Depression:*
Yes No
Yes No
41. Irritability:*
Yes No
Yes No
42. Low libido:*
Yes No
Yes No
43. Dysparonia:
Yes No
Yes No
44. Erectile dysfunction:**
Yes No
Yes No
45. Premature ejaculation:**
Yes No
Yes No