Family And Medical History Form Page 2
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6OTHER PERSONS LIVING IN THIS CHILD’S HOUSEHOLD:
NAME
SEX
AGE/GRADE
RELATIONSHIP TO CHILD
_____________
PART 2: PREGNANCY AND BIRTH HISTORY
1. Gestational Age at time of delivery (or # weeks early or late):
2. Length of Labor (in hours)?
3. What type of delivery (please circle)? Vaginal
Cesarean Section = elective or emergency
Presentation: Head, Face, Breech, Transverse
Reason for C-section
Assistance: Forceps, Vacuum, other
4. Did you experience any of the following problems during the labor/delivery? Please indicate by placing a
checkmark in the “no” or “yes” column and explain (why, what occurred, how treated etc):
ITEM
NO
YES
DESCRIPTION
EXPLANATION
1
MATERNAL infection
2
Low/high red/white blood cell count
3
Pelvis or cervical problems
4
Placenta problems
5
Dysfunctional labor
6
BABY had the cord around the neck
7
Cord problems (knots, prolapsed, compression)
8
Baby had very low or high heart rate
9
Baby had heart rate decelerations
10
Fetal distress was noted
11
Meconium was noted
5. What was the baby’s Birth Weight?
Birth Length
6. Number of Days spent in the nursery?
NICU or Newborn Nursery?
7. What was the condition of your infant while in the nursery?
Please indicate by placing a checkmark in the
“no” or “yes” column and explain (what month, why, what, what occurred, how treated etc):
ITEM
NO
YES
DESCRIPTION
EXPLANATION
1
Was blue/cyanotic at birth
2
Required stimulation to breathe
3
Required oxygen at birth
How much/what type?
4
Required resuscitation
5
Was considered small for gestational age
6
Had tremoring or seizures
Which/for how long?
Bacharach Institute for Rehabilitation, 61 W Jimmie Leeds Road, Pomona, NJ, 08234
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