Indiana Certificate Of Live Birth Worksheet Template Page 4
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30. . . . MOTHER:
MOTHER: Did you receive WIC (Women, Infants & Children) food for yourself because you
Did you receive WIC (Women, Infants & Children) food for yourself because you
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MOTHER:
MOTHER:
Did you receive WIC (Women, Infants & Children) food for yourself because you
Did you receive WIC (Women, Infants & Children) food for yourself because you
were pregnant with this child?
were pregnant with this child?
were pregnant with this child?
were pregnant with this child?
Yes
No
Unknown
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31. . . . MOTHER:
MOTHER:
MOTHER:
MOTHER: What is your height?
What is your height?
What is your height?
What is your height?
________feet _______ inches
3 3 3 3 2 2 2 2 . . . . MOTHER:
MOTHER: What was your pre
What was your pre- - - - pregnancy weight, that is, your weight immediately before you
pregnancy weight, that is, your weight immediately before you
MOTHER:
MOTHER:
What was your pre
What was your pre
pregnancy weight, that is, your weight immediately before you
pregnancy weight, that is, your weight immediately before you
became pregnant with this child?
became pregnant with this child? __________lbs.
became pregnant with this child?
became pregnant with this child?
3 3 3 3 3 3 3 3 . Mother’s weight at deliv
. Mother’s weight at delivery
ery
. Mother’s weight at deliv
. Mother’s weight at deliv
ery
ery
__________lbs.
3 3 3 3 4 4 4 4 . . . . CIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGNA A A A NCY
NCY
NCY
NCY: : : : How many cigarettes OR
How many cigarettes OR
How many cigarettes OR
How many cigarettes OR
following time periods?
following time periods?
following time periods?
following time periods?
packs of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of the
If you NEVER smoked, enter zero for each time period.
If you NEVER smoked, enter zero for each time period.
If you NEVER smoked, enter zero for each time period.
If you NEVER smoked, enter zero for each time period.
# o f c i g a r e
# o f c i g a r e t t e s
# o f c i g a r e
# o f c i g a r e
t t e s
t t e s
t t e s
# o f p a c k s
# o f p a c k s
# o f p a c k s
# o f p a c k s
Three months before pregnancy
__________
OR ____________
First three months of pregnancy
__________
OR ____________
Second three months of pregnancy __________
OR ____________
Last three months of pregnancy
__________
OR ____________
35. CURRENT MARITAL STATUS
Never Married
Widowed
Divorced
Currently Married
Married, but refusing Father’s Information
Unknown
36. Mother's name prior to her first marriage, (Maiden Name)
Mother's name prior to her first marriage, (Maiden Name)
Mother's name prior to her first marriage, (Maiden Name)
Mother's name prior to her first marriage, (Maiden Name)
_________________________________________________________________________________
First
Middle
Last
Suffix
37. MOTHER'S Marital Status, ARE YOU MARRIED TO THE FATHER OF YOUR CHILD?
[Please go to question 39
Y e s
[Please go to question 38
N o
38. If not married, has a Paternity Affidavit been completed for this child?
Yes, a paternity affidavit has been completed
I f Y e s D a t e A f f i d a v i t w a s s i g n e d : _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
No, a paternity affidavit has not been completed
I f I f I f I f N o
N o p l e a s e g o t o q u e s t i o n
p l e a s e g o t o q u e s t i o n 5 3
5 3
N o
N o
p l e a s e g o t o q u e s t i o n
p l e a s e g o t o q u e s t i o n
5 3
5 3
3 3 3 3 9 9 9 9 . . . . FATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAME
_______________________ _________________ _______________________ ______________
First
Middle
Last
Suffix(Jr., III, etc.)
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40. . . . FATHER: What is
FATHER: What is
FATHER: What is
FATHER: What is the father's
the father's
the father's date of birth? (Example: 03
the father's
date of birth? (Example: 03
date of birth? (Example: 03- - - - 04
date of birth? (Example: 03
04
04
04- - - - 1977)
1977)
1977)
1977)
___ ___/___ ___/___ ___ ___ ___ M M D D Y Y Y Y
AGE: ________________
5/25/2012
PAGE 4
VERSION 27 INDIANA'S BIRTH WORKSHEET
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