|
|
|
| Name of
Hospital : |
|
| Address
of Hospital : |
|
| Total
No. of births in this month : |
|
| Date of
birth : |
|
Mother's
Age : |
|
| Parity :
|
|
| Gestation
weeks : |
|
| Type of
Delivery : |
|
| Height
of mother : |
|
Past
Obsteric History : |
|
| Previous
Pregnancies: |
|
| Previous
H/o abortion/SB/Termination : |
|
Previous
H/O birth defect: |
Yes
No
|
| If yes,
specify : |
|
Any
H/o exposure - drugs, illness during pregnancy : |
Yes No
|
Any
ante-natal investigation : |
Yes No
|
| If yes,
specify - technique, reason and defects : |
|
Excess/deficiency
of amniotic fluid : |
Yes No
|
| Persistent
foetal malpresentation : |
Yes No
|
Social
History : |
|
| Education
of mother : |
|
| Marital
Status (yrs. of marriage) : |
|
| Religion
: |
|
| Urban/Rural
: |
|
| Joint/Nuclear
family : |
|
| Members
in the family : |
|
| Income :
|
|
BABY |
|
| Weight :
|
|
| Sex :
|
Male Female
|
| Pre-term
: |
|
| Term :
|
|
| Post-term
: |
|
Time
of recognition of defect : |
|
| If
infant died how many hours after birth : |
|
Single
or multiple malfunctions
(If multiple, enter all with diagnosis of
syndrome, if any): |
|
| Type of
abnormality : |
|
| Neurological
: |
|
| Cardiovascular
: |
|
| Renal :
|
|
| Gastro-intestinal
: |
|
| Skeletal
: |
|
| Chromosomal
: |
|
| Biochemical
: |
|
| |
