Unformatted text examine: U. S. Standard Certification From Real time BERTH Beginning Number: 1. Kid’s Title (First. Center, Last. Suf?x) 2. Time of Beginning 3. Facility Name (If not business. Town. Area. Otherwise Area From Delivery eight. State Regarding Beginning . Day Out-of Delivery (MoIDanyr) Regional File Zero . I- ,5! BIRTHPLACE (State. Territory, or Overseas Nation) ninety. Area. City. Or Location 92. Suitable. Zero. Zip code 13. Big date Registered Because of the REGISTRAR I’ 1′ DD 11. CERTIFIER’S Title: , Entitled MD You Manage You Healthcare Admin. EICNMI’CM CI Most other MIDWIFE I:We Almost every other (Specify) MM YYYY Urban area. City. Mom’s Emailing Target: nine Same as home. Layer 8. Amount. Flat Zero: Zip code: 15. Mom Partnered? Public Safeguards Matter Questioned 17. Studio «step one (NP!
Dad’s Societal Security Matter:
Have PATERNITY ACKNOWLEDGEMENT Already been Signed In the Medical? Mother’s Social Defense Number: 19. Mother’s Training (Read the . Mother From Hispanic Supply? Mother’s Race (Check one or more events to point package one most useful desciibes the greatest the container one to most useful identifies whether or not the what the mom takes into account herself are) education otherwise lchl off university compieted at mommy ls SpanlsITII-IlspaniclLaiFna. Look at the . North american country. North american country Western. Chicane I: 9th -twelfth amounts. P Rican D We: High-school graduate otherwise GED uerto a great Filipino completed :1 Sure. Cuban For the Japanese Este Specific GDIIEQG credltbetnodegree Este Sure. AS) good Bachelor’s studies (nine. BA. Ab. BS) I:We Master’s training SA? MA. MS. MEng. MEd. Yards . MBA) Este Doctorate (elizabeth. PhD. EdD) otherwise Elite group studies (e.
MD. DDS. DVM, LLB. JD) III Other Far-eastern (Specify) to help you Native Hawaiian Este Guamanian or Chamorro El Samoan Some other Paci?c Islander (Specify) Este Other (Specify) (Specify) 23. Dad’s Degree (Read the package one to most useful identifies the greatest studies orlevel away from college done during birth> 24. Father Out of Latina Origin? See the «No’ box In the event that father Is not SpanishIl-Ilspanichatlno) twenty-five. Father’s Race (View one or more crГ©er compte babel events to suggest just what father takes into account himseif getting) ‘ Q: «13:» ‘ ? . Mexican. Mexrcan Amencan. Chicano We: Sure. Puerto Rican I: Senior high school scholar or GED B Chinese accomplished El Yes. Cuban :step one Filipino 0 Certain cottage creditbutnodesree We: Sure. AA. AS) (Specify) OVietnamese __ a good Bachelor’s education (9. EA, Abdominal, BS) c Other Asian (Specify) I:I Native Hawaiian a good Guamanfart orChamono We:We Samoan :step 1 Other Pacific Islander (Specify) I :step three Other (Specify) a Master’s de- ree 3.
MA. MS. MEng. Me . MS . MBA) I: Doctorate (six. PhD, Edmcr Frofesslonal knowledge (9. MD. DDS. DVM. LLB. JD) Mother’s Medical Checklist Mom’s Name Zero. Put In which Delivery Occurred (View one to) a medical facility twenty seven. ATTENDANT’S Title. Title, And you can NH 28. Mother Transported Having MATERNAL Medical Otherwise FETAL Signs Getting Name: NP]: o Freestanding birthing Denier gEtEstFENIER II?IEEOFbF’ACILITY Mommy letter Domestic Binh: Prepared Io dellveralhame? Time Regarding Earliest FRENATAL Care See a no Prenatal Care and attention YYYY 31. Mom’s Top (feetfinchas) thirty-five. Quantity of Early in the day Real time BIRTHS (Don’t Include which boy) ‘ thirty-six. Level of Other Maternity Effects Exposure Points Within Maternity (Chock petroleum one to apply) All forms of diabetes D Prapregnancy (Analysis priorto which pregnancy) (Medical diagnosis within this maternity) D Cervical corciage D Tocolysls you Gestational Extemal cephalic version: [We Successful :step one Hit a brick wall Blood pressure level you Prepregnancy (Chronic) El Gestational (PIH.
Intercourse 4′ Big date Out-of Delivery lMoIDaIWr) t
Onset of Work (See all of that appty) Este Almost every other prior worst maternity benefit (Boasts u Premature Rupture of Walls (protonged. Unpredictable Criteria Of the Newborn (Check all of that incorporate) ‘ 4B. Infant Medical Listing Count 49. BIRTHWEIGHT (grams popular. OBSTETRIC Estimate Off GESTATEON: (complete days) NICU entryway Newborn considering surfactant replacement therapy 51. APGAR Score: Get on five minutes: In the event that 5 minute rating was lower than B, Antibiotics acquired by infant having suspected neonatal sepsis Score in the ten full minutes: Seizure otherwise really serious neurologio description 52. PLURALITY-Sin internet explorer. TwI . T’ l We. Otherwise Solitary Delivery – Created First. 2nd. 3rd. Try Child Transferred In 24 hours or less Out-of Beginning? Name Regarding Studio Kids Directed Mother’s Scientific Record Mom’s Title Zero. Performed Mom Get ch Dinner Having By herself .
DURENG It Maternity? Dominant Source of Commission For it Beginning D Privateinsuranco in order to Medicaid u Seitpay [step 3 Other (Spectra # regarding packs tiO, Mom’s Medical Record Amount 46. Particular Beginning An effective. Are dativory having forceps experimented with but unproductive? D Yes We: No B. Are delivery with cleaner removal attempted but unsuccessful? Feta: speech at the birth Este Cephalic El Breech I3 Most other D. Final station and type of beginning (Consider that) you VaginaIiSpontaneous r1 VaginaiiForceps an excellent VaginaiNacuum El Cesarean if the cesarean. MATERNAL MORBIDiTY (Glance at aIE you to definitely appiy) (Compiica?ons regarding the labor and you will deltve ry) Maternal transfuxlon 3rd or 4th training perinea! CONGENITAL Defects Of your own NEWEIORN (See petroleum that incorporate) Este Anencephaty you MeningomyelocelaiSpina bi?da |:| Cyanotic congenitat heart disease [3 Congenital diaphragmatic hernia D OmphaIOCEIe El El Este 57.
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