Blank Child Birth Certificate Texas PDF Template

Am / Pm

Single / Twin / Triplets / Quadruplets / Quintuplets

VS-109.1 REV 2/2005

MOTHER’S RESIDENCE ADDRESS

□ Yes □ No

□ Yes □ No

Mother’s Education

□8th grade or less

□9th – 12th grade, no diploma

□High School graduate or GED completed

□Some College credit, but no degree

□Associate degree (e.g., AA, AS)

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

Is Mother of Hispanic Origin?

□No, not Spanish / Hispanic / Latina

□Yes, Mexican, Mexican American, Chicana

□Yes, Puerto Rican

□Yes, Cuban

□Yes, other Spanish / Hispanic / Latina

Specify______________

What is Mother’s Race?

Father’s Education

□8th grade or less

□9th – 12th grade, no diploma

□High School graduate or GED completed

□Some College credit, but no degree

□Associate degree (e.g., AA, AS)

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

Is Father of Hispanic Origin?

□No, not Spanish / Hispanic / Latino

□Yes, Mexican, Mexican American, Chicano

□Yes, Puerto Rican

□Yes, Cuban

□Yes, other Spanish / Hispanic / Latino

Specify______________

What is Father’s Race?

Prenatal Care □ Yes □ No □ Unknown

Date of First Visit ____/____/______

Date of Last Visit ____/____/______

Total Number of Prenatal Visits for this Pregnancy: ________

Date Last Normal Menses Began ___/___/_____

Pregnancy History

Live births now living (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____

Live births now dead (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____

Date of last live birth: ____/______

MM YYYY

Number of other pregnancy outcomes (Include fetal losses of any gestational age. If this was a multiple delivery, include all fetal losses delivered before this infant in the pregnancy.

If none enter “0”.): _____

Date of last other pregnancy outcome: ____/______

MM YYYY

Infections Present and/or Treated During Pregnancy

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

□Previous preterm birth

□Other previous poor pregnancy outcome (includes perinatal death, small-for- gestational age/intrauterine growth restricted birth)

□Pregnancy resulted from infertility treatment

□Fertility-enhancing drugs, artificial insemination or intrauterine insemination

□Assisted reproductive technology

□Mother had a previous cesarean delivery

If yes, how many?_____

□Antiretrovirals administered during pregnancy or at delivery

□None of the above

HIV Test

Obstetric Procedures (check all that apply)

□Cervical cerclage

□Tocolysis

External cephalic version

□Successful □ Failed

□None of the above

Characteristics of Labor & Delivery

(check all that apply)

□Induction of labor

□Augmentation of labor

□Non-vertex presentation

□Steroids (glucocorticoids) for fetal lung maturation received by mother prior to delivery

□Antibiotics received by mother during labor

□Chorioamnionitis or maternal temperature > = 38 degrees C or

100.4degrees F

□Moderate/heavy meconium staining of the amniotic fluid

□Fetal intolerance of labor was such that one or more of the following actions was taken: in-utero resuscitative measures, further assessments, or operative delivery

□Epidural or spinal anesthesia during labor

□None of the above

Maternal Morbidity – Complications associated with Labor & Delivery

□Maternal transfusion

□Third or forth degree perineal laceration

□Ruptured uterus

□Unplanned hysterectomy

□Admission to intensive care unit

□Unplanned operating room procedure following delivery

□None of the above

Onset of Labor (check all that apply)

□Premature Rupture of the Membranes [prolonged > =12 hours]

□Precipitous Labor [< 3 hours]

□Prolonged Labor [> = 20 hours]

□None of the above

Obstetric Estimate of Gestation (completed weeks): _________

Child’s Sex: □ Male □ Female □ Not yet determined

Apgar Score: at 5 min:_______; (if less than 6) at 10 min:_______

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

□Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention)

□None of the above

Congenital Anomalies of the Newborn (check all that apply)

Was Infant Transferred within 24 hours of Delivery?

□No □ Yes, Specify Facility _________________

Is Infant Living at Time of Report?

□Yes □ No

Is Infant Being Breastfed at Discharge?

□Yes □ No

□Anencephaly

□Meningomyelocele/Spina bifida

□Cyanotic congenital heart disease

□Congenital diaphragmatic hernia

□Omphalocele

□Gastroschisis

□

□Cleft palate alone

□Down syndrome

□Karyotype confirmed

□Karyotype pending

□Suspected chromosomal disorder

□Karyotype confirmed

□Karyotype pending

Hepatitis B Immunization given?

□ Yes □ No