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Sidelines National Support Network  / Request Support


All Information Is Confidential!

The following form must be filled out in order to receive Personal Email Support or Phone Support. Rather than fill this out for someone who does not have email access, please use our toll free number: 1-888-447-4754.  Sidelines does offer international support by email only.

We do ask for sensitive and personal information such as ethnicity and medical background. Please be assured that all information collected is COMPLETELY CONFIDENTIAL. Our questions are designed to follow Center For Disease Control guidelines so that we are able to merge our confidential data with theirs. New data suggests that some medical conditions are more prevalent in certain age groups, races, and geographical locations. We are in the unique position to be able to provide the medical community with information which could improve the scope and effectiveness of prenatal care, diagnostic and treatment options.

As well as providing important medical data, the information you provide allows us to match you as closely as possible with a volunteer. Due to the high demand for online and phone support Sidelines can only offer personal support to those who are currently pregnant or in need of NICU support.  We can match you with a trained Sidelines volunteer who has previously experienced a similar pregnancy complication. Depending on which you choose, your volunteer will support you throughout the remainder of your pregnancy and / or NICU experience through email messages or by calling you on the phone.

Please note: Sidelines does not give medical advice. If you want more specific information on your treatment plan, have questions about the medications you are taking, or think you might be in pre-term labor, please call your medical professional, case manager, or local hospital.

If you would prefer for someone to contact you by phone instead of filling out this form online, or you need immediate assistance, please call our toll free number (888) 447-4754 (HI-RISK4).

If you do not need personal support but are interested in getting other information about Sidelines, please go to our Sidelines Packets and Brochures Order Form.


Please note that Sidelines will make every effort to contact you via the email address you give us. If you are a Yahoo, Hotmail, or GMail user, please be sure to check your email junk folders in case our reply gets misdirected.. If this happens to you, please set the security level to allow email from Sidelines or call: 1-888-447-4754 with any questions.






First Name     Last Name

Age   

 Occupation

Email Address***

*** Attention Spam Block users: If you are currently using your ISP "Mail Block" feature (where you won't accept email from senders you do not know), our online coordinators cannot contact you. Please turn off this feature if you want a reply from Sidelines***.

 

Partner's name

Street Address    City

State (Or Province if outside the United States)      Zip or Postal Code          Country

Home Phone Number:     

Hospital Phone Number (if hospitalized):      Extension

Name Of Medical Insurance Company (Sidelines is a free service.)

Physician's Name

Name Of Hospital Where You Will Deliver

City    State


        How did you find out about Sidelines?

 

      Type of support you would like? Email Phone

We do try to match requests for phone support with a volunteer located as close to you as possible, but our first concern is that you get support for your complication. If you are requesting phone support you will need to make the calls to your volunteer.

    Due date:(mm/dd/yy)?

    # of weeks along in current pregnancy?

    Pregnancy number 1st 2nd 3rd 4th

If more than 4th provide number

Do you have other children? yes no

What are their ages:

What is your ethnic background?
African American
Spanish/Hispanic/Latino
American Indian
Asian Indian
Alaska Native
Native Hawaiian
Chinese
Japanese
Korean
Filipino
Vietnamese
Other Pacific Islander
Other Asian
White
Other

 

        Pregnancy complications (check all that
            apply to your current pregnancy)  


Auto-immune problems Bleeding Gestational Diabetes

Type 1 Diabetes

Type 2 Diabetes
HELLP
syndrome

Hyperemesis


Hypertension (PIH)

Chronic Hypertension

Cervical
Insufficiency

Infection

Please check:
  Amniotic

  BV
  Beta Strep
  Herpes
  Vaginitis
Urinary Tract Infection

  Other

Preeclampsia Multiple Gestation
TTTS
(twin to twin transfusion
syndrome)
Twins
Triplets
Quads
Quints


IUGR

Uterine fibroids

Uterine irritability


Oligo-
hydramnios

Prior Preterm Birth (birth at less than 37 weeks) Placenta Abruption Placenta Previa


Rupture of
Membranes

Preterm Labor

Previous Stillbirth
Previous Miscarriage

Poly-
hydramnios

MOMO
(mono-chorionic
mono-amniotic
)
Pulmonary Edema Diabetic Coma Blood Clot/DVT
Renal Failure Subchorionic Hemmorhage RH Factor Disease Cancer
Work Issues
Marital Issues
Military
Uterine
Anomaly
Fetal Abnormality

 Pregnancy result of infertility management?
         
yes no

Fertility Treatments: (check all that apply)
Meds     GIFT     IVF     Embryo Xfer
Intracytoplasmic Sperm Injection (ICSI)    Selective reduction     Other

Fetal
Death

 Pregnancy Related Depression?
         
yes no

History of Post Partum Depression


 

Types of treatments you are receiving
(check all that apply to current pregnancy)

Amnio-centesis

Complete
Bedrest

Modified
Bedrest

Cerclage Home Uterine Activity Monitoring

Hospitalization

Currently
   Hospitalized

IV Hydration Therapy Ultrasound Length of hospitalization this pregnancy
Diagnostic     Testing  fFn?
positive
negative
AmniSure?
positive
negative

 

Medications

Oral Medication Heparin pump Indocin
Mag Sulfate Nifedipine Procardia

Makena/
(hydroxyprogesterone caproate injection)
Compounded 17P
Progesterone (vaginal suppositories)

Terbutaline Pump Insulin
Steroids Antibiotic Vistaril
Indomethacin Reglan Zofran
Rofecoxib Ritodrine

 

What other information would you
like to add about your pregnancy
?

     



If you could choose ONE pregnancy
complication that you would like support
for it would be:

(check box below)


Preterm labor
Cervical Insufficiency/cerclage
Multiples (twins, triplets, quads...)
Placenta previa,
Placental abruption,
Bleeding,
Hypertension,
PROM (premature rupture of membranes)
Prior preterm birth (less than 37 weeks gestation)
All others/special conditions (includes diabetes, hyperemesis,
      autoimmune, IUGR, low or high amniotic fluid, unusual maternal
      or fetal problems, multiple miscarriage or stillbirth.)


As part of our efforts to improve the value and quality of our services, we contact patients at the end of their pregnancy to collect information about the support received. May we contact you for a brief interview?

Yes     

No, I would not like to participate

 

Are you interested in helping other Moms experiencing a high risk or complicated pregnancy? Check here if you would LIKE to receive information on becoming a Sidelines volunteer after you deliver.
I am interested in learning more about becoming a Sidelines volunteer after I deliver.




After filling out the above form, click on the submit button. The information will be sent to our staff. We will be in touch with you as soon as possible regarding matching you with a Sidelines volunteer. Thanks!!


 fFN