Unformatted text message preview: You. S. Standard Certification Of Alive BERTH Birth Matter: step 1. Children’s Label (Basic. Center, Last. Suf?x) dos. Duration of Delivery 3. Business Identity (If not facilities. Town. City. Otherwise Place Regarding Beginning seven. County From Delivery . Big date Away from Birth (MoIDanyr) Local File No . I- ,5! BIRTHPLACE (State. Region, or Overseas Nation) 90. Town. City. Otherwise Place 92. Apt. No. Area code thirteen. Go out Recorded Because of the REGISTRAR I’ 1′ DD eleven. CERTIFIER’S Term: , Titled MD U Manage You Health Admin. EICNMI’CM CI Most other MIDWIFE We:We Other (Specify) MM YYYY City. Town. Mother’s Mailing Target: nine Same as home. Sheet 8. Count. Apartment Zero: Area code: 15. Mom Married? Personal Security Amount Questioned 17. Business « 1 (NP!

Father’s Personal Security Count:

Provides PATERNITY ACKNOWLEDGEMENT Come Closed Regarding the Hospital? Mom’s Social Protection Count: 19. Mother’s Education (Look at the . Mom From Latina Origin? Mother’s Race (See a minumum of one races to indicate container you to ideal desciibes the highest the package you to definitely best describes whether or not the exactly what the mother considers herself become) studies otherwise lchl away from college compieted at mommy ls SpanlsITII-IlspaniclLaiFna. Browse the . North american country. Mexican Western. Chicane We: 9th -12th degree. P Rican D We: Highschool graduate or GED uerto a beneficial Filipino complete :step 1 Yes. Cuban Inside Japanese El Some GDIIEQG credltbetnodegree Este Sure. AS) a good Bachelor’s studies (nine. BA. Abdominal. BS) I:I Master’s knowledge SA? MA. MS. MEng. MEd. Yards . MBA) El Doctorate (elizabeth. PhD. EdD) or Professional knowledge (elizabeth.

MD. DDS. DVM, LLB. JD) III Other Far-eastern (Specify) in order to Native Hawaiian Este Guamanian or Chamorro El Samoan To other Paci?c Islander (Specify) Este Other (Specify) (Specify) 23. Dad’s Education (See the field you to better identifies the best knowledge orlevel out-of university finished during the time of birth> twenty four. Father Away from Hispanic Origin? See the « No’ box When the father Isn’t SpanishIl-Ilspanichatlno) 25. Dad’s Competition (Take a look at no less than one racing to indicate just what father takes into account himseif becoming) ‘ Q: « 13: » ‘ ? . North american country. Mexrcan Amencan. Chicano We: Sure. Puerto Rican We: Highschool graduate otherwise GED B Chinese completed El Sure. Cuban :1 Filipino 0 Particular cottage creditbutnodesree We: Yes. AA. AS) (Specify) OVietnamese __ good Bachelor’s education (nine. EA, Abdominal, BS) c Other Far-eastern (Specify) I:I Native Hawaiian an excellent Guamanfart orChamono We:We Samoan :step 1 Most other Pacific Islander (Specify) We :3 Most other (Specify) good Master’s de- ree step 3.

MA. MS. MEng. Me personally . MS . MBA) I: Doctorate (6. PhD, Edmcr Frofesslonal knowledge (9. MD. DDS. DVM. LLB. JD) Mother’s Scientific Number Mother’s Term No. Place Where Birth Took place (Consider you to) a hospital twenty seven. ATTENDANT’S Term. Title, And you will NH 28. Mother Transported Getting MATERNAL Scientific Otherwise FETAL Indicators To possess Identity: NP]: o Freestanding birthing Denier gEtEstFENIER II?IEEOFbF’ACILITY Mommy n Family Binh: Arranged Io dellveralhame? Date Out of First FRENATAL Care and attention Go to a zero Prenatal Care and attention YYYY 29. Mother’s Level (feetfinchas) thirty-five. Quantity of Previous Alive BIRTHS (Don’t Become which child) ‘ thirty-six. Level of Other Pregnancy Outcomes Risk Points In this Pregnancy (Chock oil that pertain) All forms of diabetes D Prapregnancy (Analysis priorto this pregnancy) (Analysis in this maternity) D Cervical corciage D Tocolysls u Gestational Extemal cephalic variation: [We Winning :1 Unsuccessful Blood pressure level you Prepregnancy (Chronic) Este Gestational (PIH.

Intercourse 4′ Day Away from Delivery lMoIDaIWr) t

Onset of Work (Check all that appty) El Almost every other prior bad maternity lead (Boasts you Early Rupture of the Walls (protonged. Unpredictable Conditions Of one’s Infant (Look at all that use) ‘ 4B. Infant Medical Number Amount forty-two. BIRTHWEIGHT (g well-known. OBSTETRIC Guess From GESTATEON: (complete days) NICU entry Infant given surfactant replacement for cures 51. APGAR Score: Rating at five full minutes: If 5 moment rating was lower than B, Antibiotics received by infant for suspected neonatal sepsis Score in the ten full minutes: code promo blackplanet Seizure otherwise significant neurologio breakdown 52. PLURALITY-Sin ie. TwI . T’ l We. If you don’t Single Beginning – Created Very first. 2nd. 3rd. Try Baby Directed In 24 hours or less Out of Delivery? Identity Away from Facility Kid Transferred Mother’s Medical Checklist Mother’s Term No. Performed Mother Get ch Dinner For By herself .

DURENG So it Maternity? Dominating Supply of Percentage For this Birth D Privateinsuranco to Medicaid you Seitpay [step 3 Almost every other (Spectra # of bags tiO, Mom’s Medical List Matter 46. Style of Delivery A good. Is dativory which have forceps experimented with but unproductive? D Sure I: No B. Try beginning with machine extraction attempted however, unproductive? Feta: demonstration during the birth El Cephalic El Breech I3 Other D. Last channel and kind of beginning (Have a look at one) you VaginaIiSpontaneous r1 VaginaiiForceps a beneficial VaginaiNacuum Este Cesarean if cesarean. MATERNAL MORBIDiTY (View aIE one appiy) (Compiica?ons for the work and you may deltve ry) Maternal transfuxlon 3rd otherwise 4th degree perinea! CONGENITAL Defects Of one’s NEWEIORN (Have a look at oils you to definitely use) Este Anencephaty u MeningomyelocelaiSpina bi?da |:| Cyanotic congenitat heart problems [step 3 Congenital diaphragmatic hernia D OmphaIOCEIe Este El Este 57.