What week did you have your PROM? 

What week did you give birth? 

Did your child survive? Yes No

Did your child have any problems/disabilities?
Yes NoToo early to say, but looks fine this far

Were there other complications that caused the birth other than PROM?
(Placental Abruption, Previa, etc.) No  I don´t know

Did you have a diagnosis of an incompetant cervix?Yes No

Did you have fibroids? YesNo

Did you have an unusual shape or placement of the uterus? Yes No

Did you notice or have a diagnosis of a leaking membrane prior to the rupture? YesNo

Did you have a diagnosis of too much fluid or too little? 
Too much fluid Normal Too little fluid

Did you yeast infection medicine shortly before the PROM (1-2 weeks)? YesNo

If so, did you use medication? YesNo

Did you have a vaginal infection shortly before the PROM (1-2 weeks)? YesNo

If so, did you use medication? YesNo

Did you have unprotected sex within 5 days of the PROM? Yes No

Did you have any noticable or severe stress near the time of your PROM? YesNo

Did you have an amnio or CVS within 3 weeks of your PROM? YesNo

Did you use any prescription medication within 1-2 weeks of PROM? YesNo

Did you use any over the counter medications within 1-2 weeks of PROM?
(Afrin, tylenol, sudafed, robitussin, etc.) YesNo

Did you do any heavy excercise or lifting within one week of PROM? YesNo

Did the doctor check the amniotic sac for any infections after delivery? YesNo
If so, please state the type of infection.

How old were you at the time of your PROM? 

Is there anything else that you can think of that might have contributed to your PROM?