Indiana Certificate Of Live Birth Worksheet Template (Page 7 of 12) in pdf

63. Date of last other pregnancy outcome (Date when last pregnancy which did not result in a

live birth ended):

_____ _____/_____ _____ _____ _____ M M Y Y Y Y

64. Risk factors in this pregnancy (Check all that apply):

None

Diabetes - (Glucose intolerance requiring treatment)

Prepregnancy - (Diagnosis prior to this pregnancy)

Gestational - (Diagnosis in this pregnancy)

Hypertension - (Elevation of blood pressure above normal for age, gender, and physiological condition.)

Prepregnancy - (Chronic) (Elevation of blood pressure above normal for age, gender, and physiological condition)

(Diagnosed prior to the onset of this pregnancy)

Gestational - (PIH, preeclampsia,) (Elevation of blood pressure above normal for age, gender, and physiological

condition) (Diagnosed during this pregnancy) May include proteinuria (protein in the urine) without seizures or coma and pathologic

edema (generalized swelling, including swelling of the hands, legs and face)

Eclampsia ( Pregnancy induced hypertension with proteinuria with generalized seizures or coma. May include pathologic

edema)

Previous preterm births – ( History of pregnancy(ies) terminating in a live birth less than 37 completed weeks of gestation

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

(History of pregnancies contuining into the 20

week of gestation and resulting in any of the listed outcomes. Perinatal death includes

fetal and neonatal deaths)

Pregnancy resulted from infertility treatment – Any assisted reproduction technique used to initiate the pregnancy. Includes fertility-

enhancing drugs(e.g. Clomid, Pergonal) artifical insemination, or intrauterine insemation and assisted reproduction technology (ART)

procedures(e.g. IVF, GIFT and ZIFT)

fertility-enhancing drugs(e.g.

F e r t i l i t y e n h a n c i n g d r u g s , a r t i f i c i a l i n s e m i n a t i o n , i n t r a u t e r i n e i n s e m i n a t i o n ( A n y

Clomid, Pergonal) artifical insemination, or intrauterine insemation used to initate the pregnancy.

A s s i s t e d r e p r o d u c t i v e t e c h n o l o g y – A n y a s s i s t e d r e p r o d u c t i o n t e c h n o l o g y ( A R T ) t e c h n i c a l p r o c e d u r e s ( e . g .

i n v i t r o f e r t i l i z a t i o n ( I V F ) , g a m e t e i n t r a f a l l o p i a n t r a n s f e r ( G I F T ) , Z I F T ) u s e d t o i n i t a t e t h e p r e g n a n c y .

Mother had a previous cesarean delivery (Previous operative delivery by extraction of the fetus, placenta and membranes through

an incision in the maternal abdominal and uterine walls)

If Yes, how many____

A n t i r e t r o v i r a l s a d m i n i s t e r e d d u r i n g p r e g n a n c y o r a t d e l i v e r y

G r o u p B S t r e p

65. Infections present and/or treated during this pregnancy - (Present at start of pregnancy or confirmed

diagnosis during pregnancy with or without documentation of treatment.) (Check all that apply):

None

Gonorrhea - (a diagnosis of or positive test for Neisseria gonorrhoeae)

Syphilis - (also called lues - a diagnosis of or positive test for Treponema pallidum)

Chlamydia - (a diagnosis of or positive test for Chlamydia trachomatis)

Hepatitis B - (HBV, serum hepatitis - a diagnosis of or positive test for the hepatitis B virus)

Hepatitis C - (non A, non B hepatitis, HCV - a diagnosis of or positive test for the hepatitis C virus)

6 6 6 6 6 6 6 6 . Was a S

. Was a Standard Licensed Diagnostic test for HIV performed for the Mother?

tandard Licensed Diagnostic test for HIV performed for the Mother?

. Was a S

tandard Licensed Diagnostic test for HIV performed for the Mother?

Y E S

I f Y e s g i v e t h e d a t e t h e s p e c i m e n w a s t a k e n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )

I f Y e s w h e n w a s t h e t e s t p e r f o r m e d ?

D u r i n g p r e g n a n c y

T i m e o f D e l i v e r y

I f Y e s w h e n w a s t h e t e s t p e r f o r m e d ?

D u r i n g p r e g n a n c y

T i m e o f D e l i v e r y

N O

I f N o g i v e r e a s o n ( c h e c k o n e b e l o w )

I f N o g i v e r e a s o n ( c h

e c k o n e b e l o w )

N O

I f N o g i v e r e a s o n ( c h

e c k o n e b e l o w )

M o t h e r ' s R e f u s a l

H I V S t a t u s K n o w n

I n s u r a n c e w o u l d n o t p a y

M o t h e r ' s R e f u s a l

H I V S t a t u s K n o w n

I n s u r a n c e w o u l d n o t p a y

O t h e r ( s p e c i f y ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

U n k n o w n ( R e a s o n w h y t h e r e w a s n o t e s t i s u n k n o w n )

U n k n o w n

( U n k n o w n w h e t h e r o r n o t t h e t e s t w a s p e r f o r m e d . )

( U n k n o w n w h e t h e r o r n o t t h e t

e s t w a s p e r f o r m e d . )

U n k n o w n

( U n k n o w n w h e t h e r o r n o t t h e t

e s t w a s p e r f o r m e d . )

5/25/2012

PAGE 7

VERSION 27 INDIANA'S BIRTH WORKSHEET

Indiana Certificate Of Live Birth Worksheet Template Page 7

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