Name
First Name
Last Name
Mother's age
Father's age
Birth defects
Achondroplasia
Cleft palate
Clubfoot
Congenital dislocated hip
Down syndrome
Marfan syndrome
Phenylketonuria (PKU)
Spina bifida
Structural heart defect
Tay-Sachs disease
Unknown
None
Other
Complications during pregnancy
Ectopic pregnancy
Gestational diabetes
High Blood Pressure / Hypertension
Hyperemesis Gravidarum
Low birth weight
Preeclampsia
Preterm labor (before 37 weeks)
Unknown
None
Other
Complications during labor
Cephalopelvic disproportion (CPD)
Excessive bleeding
Failure to progress
Fetal distress
Perinatal asphyxia
Placenta previa
Rapid labor
Shoulder dystocia
Uterine rupture
Unknown
None
Other
Newborn complications
Anencephaly
Hydrocephalus
Jaundice
Necrotizing Enterocolitis (NEC)
Respiratory Distress Syndrome
Sepsis
Thrush
Unknown
None
Other
Time in labor
Birth weight
Should be Empty: