Birth Certicate Worksheet for Health and Medical Information

(To be completed by Mother or Father of Child) Please ll out both sides of this form -- any boxes left blank will delay the certicate from being led.
First Middle Last

State of Colorado

COUNTY OFFICE USE ONLY

Sufx

Childs Full Name:

Gender: Single, Twin, Triplets etc 1, 2, 3, ... Month Day Year Hr. Min.

General

Male

Female

Plurality: ________ Yes

First

Birth Order: _______

Date of Birth:_____/____/______ Time of birth: ____:____ Is infant living at time of report: Yes No

AM PM Military

Is infant receiving breast milk? Name of Mother: Did mother get WIC food? Attendant Name:
Person who caught the baby

No
Middle

Maiden Name

Current Last Name

Yes

No
First

Unknown
Middle Initial Last

Place of Birth

Attendant Type: Attendants Address:

MD

DO

CNM

Registered Midwife
Street Street

Other: (specify)
City & County City & County State State Zip Zip

Address where baby was born: Infant transferred within 24 hours of delivery: Mother transferred prior to delivery: Principle source of payment: No Prenatal Care Yes Yes No If Yes, name facility transferred to:

No If Yes, name facility transferred from: Medicaid; #________________

YYYY

Private insurance
MM DD

Self-pay
MM

Other (specify:_______________________)
DD YYYY

Number of visits for Date of Last Prenatal care visit: ______/______/________ Prenatal care: Date of First Prenatal care visit: ______/______/________ Month Prenatal care began: (1st, 2nd, 3rd ...) Prenatal Care Provider: Number of live births now living?
(not including this one)

Prenatal 1

Date of last live birth? (not including this one)

Month Date Year

0, 1, 2, 3 ...

Now Deceased?

Number of other outcomes?

(miscarriage or abortion at any time during pregnancy)

Date of last other outcome?

Month Date Year

/ / Mothers height:

/ Unknown

Mothers prepregnancy weight: Unknown

Date of last normal menses began: _____/_____/______

# of cigarettes/ day ____________ ____________ ____________ ____________ # of drinks/ week _________ _________ _________ _________

CIGARETTE SMOKING & ALCOHOL USE BEFORE AND DURING PREGNANCY: (For each time period, enter number of cigarettes and number of alcoholic drinks. If none, enter 0. Average number of cigarettes smoked per day and alcoholic drinks per week.) RISK FACTORS IN THIS PREGNANCY (Check all that apply) DIABETES Prepregnancy (Diagnosis prior to this pregnancy) Gestational (Diagnosis in this pregnancy) HYPERTENSION Prepregnancy (Chronic) Gestational (PIH, preeclampsia) Eclampsia HELLP Syndrome Previous preterm birth Previous infant > 4000 grams, (8.8 Lbs.) Other previous poor pregnancy outcome (Includes perinatal death, small-for-gestational age/intrauterine growth restricted birth) Three months before pregnancy: First three months of pregnancy: Second three months of pregnancy: Last three months of pregnancy:

Prenatal 2

Pregnancy resulted from infertility treatment--Check all that apply Fertility-enchancing drugs, Articial insemination or intrauterine insemination Assisted reproductive technology (e.g., in viro fertilization (IVF), gamete intrafallopian transfer (GIFT) Mother had a previous cesarean delivery If yes, how many? __________ Asthma Genital Herpes at time of delivery Other (Specify) ____________________________________________________ None Unknown Month Day Year

Check blood screening that apply: No blood test done for this pregnancy
Gonorrhea CMV Hepatitis B Rubella Herpes Simplex Virus

Syphillis HIV Hepatitis-B

Bacterial Vaginosis

Date of screen: Date of screen: Date of screen:

Hepatitis C

/ / /

/ / /

Unknown

INFECTIONS PRESENT/TREATED DURING THIS PREGNANCY (Check all that apply) Group B Strep (GBS) None HIV/AIDS Other (Specify) ________________________________________________________________________

Signature of Registrar:

Name of County:

Please complete all sections of worksheet to avoid any delays in ling. Mothers weight at delivery: Unknown
OBSTETRIC PROCEDURES (Check all that apply)

COUNTY OFFICE USE ONLY

ONSET OF LABOR (Check all that apply) Premature Rupture of the Membrances (prolonged, >/= 12 hrs.) Precipitous Labor (< 3 hrs.) Prolonged Labor (>/= 20 hrs.) Other (specify) ___________________________________________ None Unknown Cervical carciage Tocolysis External cephalic version: Other (specify) ___________________________________________________ METHOD OF DELIVERY Was delivery with forceps attempted? Yes No If yes, was it unsuccessful? Yes No Was delivery with vacuum extraction attempted but unsuccessful? Yes No Fetal presentation at birth Cephalic (head down) Breech (bottom rst) Other Final route and method delivery (Check one) Vaginal/Spontaneous Vaginal/Forceps Vaginal/Vacuum Cesarean If cesarean, was a trial of labor attempted? Yes No Successful Failed None Unknown

CHARACTERISTICS OF LABOR AND DELIVERY (Check all that apply) Induction of labor Augmentation of labor Non-vertex presentation Steriods (glucoconticoids) for fetal lung maturation received by the mother prior to delivery Antibiotics received by the mother during labor Clinical chorioamnionitis diagnosed during labor or maternal temperature 38C (110.4F) Moderate/heavy meconium staining of the amniotic uid Fetal intolerance of labor such that one or more of the following action was taken: in-utero resuscitative measures, further fetal assessment, or operative delivery Epidural or spinal anesthesia during labor Other (Specify) _________________________ None Unknown Specify lbs or grams

MATERNAL MORBIDITY (Check all that apply) (Complications associated with labor and delivery) Maternal transfusion Third or fourth degree perineal laceration Ruptured uterus Unplanned hysterectomy Admission to intensive care unit Unplanned operating room procedure following delivery VBAC Abruptio Plancenta Placenta Previa Cephalopelvic disproportion (CPD) Cord prolapse Other (Specify) _____________________ None Unknown

LD

Childs birth weight: Was a Hepatitis B Immunization given to Infant?

Attendants estimate of weeks gestation: Obstetric __________________ Clinical Yes No

at 5 minutes

at 10 minutes

Apgar score: Not Taken

MM DD

________ _________ Unknown

YYYY

If Yes, Date Given: _______ _______ ____________

ABNORMAL CONDITIONS OF THE NEWBORN (Check all that apply) Assisted ventilation required immediately following delivery Assisted ventilation required for more than six hours NICU admission Newborn given surfactant replacement therapy Antibiotics received by the newborn for suspected neonatal sepsis Seizure or serious neurologic dysfunction Signicant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which required intervention) Meconium aspiration syndrome Supplemental oxygen needed > 4 hours Hypoglycemia Hyperbilirubinemia Hyaline membrane disease/RDS Other (Specify) ____________________________________________ None Unknown CONGENITAL ANOMALIES OF THE NEWBORN (Check all that apply) Anemcephaly Meningomyelocete/Spina bida Cyanotic congenital heart disease Congenital diaphragmatic hernia Omphalocete Gastroschisis Limb reduction defect (exclusing congenital amputation and dwarng syndromes) Cleft Lip with or without Cleft Palate Hypospadias Down Syndrome Karyotype conrmed (Specify) ______________________________________ Karyotype pending Other chromosomal disorder Diagnosis conrmed (Specify) ______________________________________ Diagnosis pending Urogenital anomalies (Specify) __________________________________________________ Circulatory/respiratory anomalies (Specify) ________________________________________ Musculoskeletal/integumental anomalies (Specify) _____________________________________________________________ Other (Specify) ______________________________________________________________ None Unknown

I certify that the above information is accurate to the best of my knowledge. In the event an error is made on this birth certificate by the hospital or county registrar during the registration process, I authorize the hospital or county registrar to act on my behalf as my legal representative to correct the error.
_______________________________________________________ Informant Signature _________________________________ Date

I:\HSVR\DATAMGT\FORMS2007

Child Med

County worksheet_birth_personnel (rev09/07)