FROM G P MOTHER, WEEKS AOG

FROM G P MOTHER, WEEKS AOG Del. Via ( ) NSD

Del. Via ( ) NSD ( ) CS to _________________________
( ) CS to _________________________
Age: _____ Status: ______ Phil Type: _______ Room #: ______
Age: _____ Status: ______ Phil Type: _______ Room #: ______ Contact #: ___________________ Religion: _____________
Contact #: ___________________ Religion: _____________ Address: _________________________________________
Address: _________________________________________
BW: Kg ( lbs, oz) AS: ___/___
BW: Kg ( lbs, oz) AS: ___/___ DIAGNOSIS: _______________________________________
DIAGNOSIS: _______________________________________
OB: ________________ PEDIA: _________________
OB: ________________ PEDIA: _________________
MATERNAL HISTORY:
MATERNAL HISTORY: ( ) Asthma ( ) Cord Coil x ____
( ) Asthma ( ) Cord Coil x ____ ( ) DM ( ) F/D Allergy
( ) DM ( ) F/D Allergy ( ) UTI ( ) PROM
( ) UTI ( ) PROM ( ) Cough ( ) LBOW
( ) Cough ( ) LBOW ( ) PRE-EC ( ) Hepa B
( ) PRE-EC ( ) Hepa B
Mother’s Lab Result:
Mother’s Lab Result: WBC: _____ Hgb: _____ Blood type: ____ Hbsag: _____
WBC: _____ Hgb: _____ Blood type: ____ Hbsag: _____ U/A: _____
U/A: _____ Antenatal done by: ______________________
Antenatal done by: ______________________ Gender of the Baby: ____ Blood type: ____ Time out: _____
Gender of the Baby: ____ Blood type: ____ Time out: _____
Hepa B: _____ Hepa B Ig: ______
Hepa B: _____ Hepa B Ig: ______ BCG: _______
BCG: _______ NBS: _______
NBS: _______ NBHT: ______
NBHT: ______
Last Dose:
Last Dose:
 FROM G P MOTHER, WEEKS AOG
FROM G P MOTHER, WEEKS AOG Del. Via ( ) NSD
Del. Via ( ) NSD ( ) CS to _________________________
( ) CS to _________________________
Age: _____ Status: ______ Phil Type: _______ Room #: ______
Age: _____ Status: ______ Phil Type: _______ Room #: ______ Contact #: ___________________ Religion: _____________
Contact #: ___________________ Religion: _____________ Address: _________________________________________
Address: _________________________________________
BW: Kg ( lbs, oz) AS: ___/___
BW: Kg ( lbs, oz) AS: ___/___ DIAGNOSIS: _______________________________________
DIAGNOSIS: _______________________________________
OB: ________________ PEDIA: _________________
OB: ________________ PEDIA: _________________
MATERNAL HISTORY:
MATERNAL HISTORY: ( ) Asthma ( ) Cord Coil x ____
( ) Asthma ( ) Cord Coil x ____ ( ) DM ( ) F/D Allergy
( ) DM ( ) F/D Allergy ( ) UTI ( ) PROM
( ) UTI ( ) PROM ( ) Cough ( ) LBOW
( ) Cough ( ) LBOW ( ) PRE-EC ( ) Hepa B
( ) PRE-EC ( ) Hepa B
Mother’s Lab Result:
Mother’s Lab Result: WBC: _____ Hgb: _____ Blood type: ____ Hbsag: _____
WBC: _____ Hgb: _____ Blood type: ____ Hbsag: _____ U/A: _____
U/A: _____ Antenatal done by: ______________________
Antenatal done by: ______________________ Gender of the Baby: ____ Blood type: ____ Time out: _____
Gender of the Baby: ____ Blood type: ____ Time out: _____
Hepa B: _____ Hepa B Ig: ______
Hepa B: _____ Hepa B Ig: ______ BCG: _______
BCG: _______ NBS: _______
NBS: _______ NBHT: ______
NBHT: ______
Last Dose:
Last Dose: