Birth Defect Client Intake Form
RH - MOTHER AND FATHER
WEIGHT BEFORE PREGNANCY: lbs.
TOTAL WEIGHT GAIN DURING PREGNANCY: lbs.
TAKING ANY PRESCRIPTION OR NONPRESCRIPTION DRUGS AT TIME OF PREGNANCY - DURING PREGNANCY:
SMOKING DURING PREGNANCY:
CAFFEINE INTAKE DURING PREGNANCY:
ALCOHOL INTAKE DURING PREGNANCY:
EXPOSED TO ANY CHEMICALS DURING PREGNANCY:
X-RAYS DURING PREGNANCY:
FAMILY HISTORY
EPILEPSY/SEIZURES:
BIRTH DEFECTS:
MENTAL RETARDATION:
RH PROBLEMS:
MOTHER'S MEDICAL HISTORY
HYPERTENSION:
ALLERGIES:
ASTHMA:
DIABETES:
FATHER'S HEALTH:
COURSE OF PREGNANCY
HYPERTENSION:
BLEEDING:
NAUSEA/VOMITING:
DIARRHEA:
PROTEIN IN URINE:
EDEMA:
ILLNESSES:
ACCIDENTS:
GIVEN ANY MEDICATION DURING PREGNANCY:
PRENATAL VISITS:
WHEN:
WHO SEEN:
WHAT DONE:
INSTRUCTIONS GIVEN:
ULTRASOUND - WHY DONE - DATE:
OXYTOCIN CONTRACTION TEST/NON STRESS TEST - WHY DONE - DATE:
SPOTTING DURING PREGNANCY:
WHEN FIRST FELT BABY MOVE - ANY CHANGES DURING PREGNANCY:
PRENATAL CLASSES:
WORK THROUGHOUT PREGNANCY:
JOB:
ANY LIMITATIONS:
WHEN STOPPED:
LABOR STARTED
DOCTOR CALLED - WHEN:
INSTRUCTIONS RECEIVED:
CONTRACTIONS:
FREQUENCY:
DURATION:
HOSPITAL ADMISSION:
SEQUENCE OF LABOR:
WATER BROKE - WHEN:
TIME FETAL MONITOR APPLIED:
PROBLEMS ON MONITOR:
TIME MEMBRANES RUPTURED:
ARTIFICIAL RUPTURE OF MEMBRANES BY PHYSICIAN:
NATURAL RUPTURE OF MEMBRANES:
APPEARANCE OF FLUID:
AMOUNT:
INTRAVENOUS FLUIDS:
MEDICATIONS:
PITOCIN:
EPIDURAL:
PHYSICIAN'S PRESENCE:
ANALGESIC:
BLEEDING DURING LABOR:
DILATION/EFFACEMENT/POSITION/STATION:
DELIVERY
TIME SPENT PUSHING:
TRANSFER TO DELIVERY ROOM:
VAGINAL DELIVERY:
WHO PERFORMED:
WHO ELSE PRESENT:
FORCEPS:
REMARKS BY PERSONNEL:
C-SECTION:
REPEAT:
EMERGENCY:
WHO PERFORMED:
OTHER PERSONNEL PRESENT:
PEDIATRICIAN PRESENT:
TIME REQUIRED:
NEWBORN:
APGAR SCORES:
BIRTH WEIGHT:
CRY/COLOR/MUSCLE TONE/BREATHING:
CORD AROUND NECK:
RESUSCITATION:
HOW LONG:
WHAT WAS DONE:
INFANT'S APPEARANCE:
MEDICATIONS GIVEN:
INJURIES SUFFERED BY INFANT:
NURSERY ADMISSION:
CONVERSATIONS WITH ANY MEDICAL PERSONNEL RE: INCIDENTS/CAUSE:
CLIENT'S SCHOOLING (MOTHER)
HIGH SCHOOL:
COLLEGE:
CLIENT'S WORK EXPERIENCE (MOTHER)
POSITION:
SUPERVISOR:
PERIOD EMPLOYED:
SALARY/WAGE RATE: CLIENT'S SCHOOLING (FATHER)
HIGH SCHOOL:
COLLEGE: CLIENT'S WORK EXPERIENCE (FATHER)
POSITION:
SUPERVISOR:
PERIOD EMPLOYED:
SALARY/WAGE RATE: