VS-109.2 (09/11)
Medical Data Worksheet for Child’s Birth Certificate
This form to be completed by hospital staff. This data will be used to populate the medical data portion of the birth
certificate for the newborn. The medical data is required to be reported within five days of the birth. [HSC
§192.003]
PATIENT REFERRENCE:
MOTHER MR# _________________________________________
NEWBORN MR# ___________________________________________
MOTHER’S NAME ______________________________________
NEWBORN NAME _________________________________________
MEDICAID# ___________________________________________
DOB ____________________________________________________
DELIVERING DR _______________________________________
DATE AOP SENT__________________________________________
MOTHER TRANSFERRED _______________________________
SOURCE OF PAYMENT FOR DELIVERY ______________________
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Born at Facility
Born En Route
Foundling
Home Birth
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Prenatal Care
Source of Prenatal Care
Yes
No
Unknown
(check all that apply)
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____/____/______
None
Midwife
Date of First Visit
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__________________
Hospital Clinic
Other, Specify
____/____/______
Date of Last Visit
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Public Health Clinic
Unknown
Total Number of Prenatal Visits for this Pregnancy: ________
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Private Physician
___/___/_____
Date Last Normal Menses Began
Risk Factors in this Pregnancy
(check all that apply)
Pregnancy History
Diabetes
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Live births now living (Do not include this birth. For multiple
Prepregnancy (diagnosis prior to this pregnancy)
st
deliveries, do not include the 1
born in the set if completing
□
_____
Gestational (diagnosis in this pregnancy)
this worksheet for that child. If none enter “0”.):
Live births now dead (Do not include this birth. For multiple
Hypertension
st
deliveries, do not include the 1
born in the set if completing
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Prepregnancy (chronic)
_____
this worksheet for that child. If none enter “0”.):
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Gestational (PIH, preeclampsia)
____/______
Date of last live birth:
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Eclampsia
MM YYYY
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Previous preterm birth
Number of other pregnancy outcomes (Include fetal losses
of any gestational age. If this was a multiple delivery, include
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Other previous poor pregnancy outcome (includes perinatal death, small-for-
all fetal losses delivered before this infant in the pregnancy.
gestational age/intrauterine growth restricted birth)
_____
If none enter “0”.):
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Pregnancy resulted from infertility treatment
____/______
Date of last other pregnancy outcome:
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Fertility-enhancing drugs, artificial
MM YYYY
insemination or intrauterine insemination
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Infections Present and/or Treated During
Assisted reproductive technology
Pregnancy
□
(check all that apply)
Mother had a previous cesarean delivery
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_____
If yes, how many?
Gonorrhea
Hepatitis B
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Antiretrovirals administered during pregnancy or at delivery
Syphilis
Hepatitis C
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Chlamydia
None of the above
None of the above
HIV Test
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HIV test done Prenatally
Yes
No
Unknown
HIV test done at Delivery
Yes
No
Unknown
(check all that apply)
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First Trimester
Third Trimester
Infant tested for HIV at birth
Yes
No
Unknown
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Second Trimester
Unknown
None