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MoonDragon's Pregnancy Information
MASSACHUSETTS BIRTH REGISTRATION
OF CHILDREN BORN AT HOME

(An online-electronic version of the official worksheet.)





This is not an official worksheet, but can be printed out and used to initially fill out any information needed at the time of birth. For an updated/revised official document write to the address given below.

COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF PUBLIC HEALTH
REGISTRY OF VITAL RECORDS AND STATISTICS
150 Mount Vernon Street
Dorchester, MA 02125
(617) 740-2300





BIRTH REGISTRATION OF CHILDREN
BORN AT HOME



City/Town Clerk: For non-hospital births registered in your office, please return this completed worksheet with the Registry Statistical Copy of the legal birth certificate to:

Birth Statistics Unit,
Registry of Vital Records and Statistics,
150 Mount Vernon Street
Dorchester, MA 02125


Rev. August 2000





Argeo Paul Cellucci, Governor
Jane Swift, Lt. Governor
William D. O'Leary, Secretary
Howard K. Koh, M.D., M.P.H., Commissioner

THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES
DEPARTMENT OF PUBLIC HEALTH
Registry of Vital Records and Statistics
150 Mount Vernon Street, 1st Floor
Dorchester, MA 02125
TELEPHONE: 617 740-2600


REGISTRATION OF HOME BIRTHS


It is extremely important that every child have his or her birth properly registered in a timely manner. If a birth is not registered within 365 days, the process becomes very complicated, and may cause your child difficulties throughout his or her life. If you are registering a birth that occurred more than 365 days ago, check with the city or town clerk where the birth occurred for more information.

Under Massachusetts law, there are four distinct methods for registering births:
    1. Hospital Births - If a birth occurs in a hospital, the attendant at birth is responsible for reporting to the hospital administrator. The hospital administrator is then responsible reporting to the city or town clerk where the birth occurred and to the State Department of Health.

    2. Non-Hospital Births Attended by a Physician--The physician is responsible for reporting to the city or town clerk where the birth occurred and to the State Department of Public Health.

    3. Non-Hospital Births Attended by Someone Other than a Physician--The parent(s) is (are) responsible for reporting within 40 days of the birth to the city or town clerk where the birth occurred with appropriate documentary evidence.

    4. Non-Hospital Births with Mother and/or Infant Transferred to an In-Patient Hospital for Post Natal Care - The hospital will prepare the birth certificate and forward it to the city or town clerk where the birth occurred.

For situation #3 above (a home birth not attended by a physician and where the mother and/or infant were not transferred to a hospital for post-natal care), specific evidence is required by law. These requirements are listed below.

FACTS OF BIRTH:

Any one or more of the following may be used to establish the facts of the birth:
    1. Notarized statement of the attendant (any attendant except the father or other close family member, for instance a non-family midwife or friend). This statement must attest to the date, time, and place of the birth as well as the sex of the child and the name of the mother.

    2. If the attendant was the father or other close family member (such as the grandmother of the child, or sister or brother of the mother), a notarized statement from the attendant is required as which includes those items listed in # 1 above, as well as one of the following:
      a. If other individuals were present at the birth, a notarized statement from a witness stating that they were a witness to the birth at the specified date, time or place.

      b. If no one else was present, notarized statements from the mother and the attendant stating the facts of the case as well as the fact that no one else was present.

      c. A notarized statement from a physician who examined the child for post natal care shortly after birth stating the facts of the birth as listed in #1 above.


PLACE OF BIRTH
    1. If the birth occurred at the residence of the parents, proof of residence is required. The best items are street listing, voter registration, or assessors records for the year of the birth. If none of these are available, check with the city or town clerk where the birth occurred for more information.

    2. If the birth occurred at someone else's residence, a notarized affidavit from the resident is necessary stating that the birth took place at their home and then proof of residence is necessary for that individual.

MARITAL STATUS

Under Massachusetts law, the marital status of the parents determines the accessibility of the record as well as the method used to add father's information to the record.
    If the parents are married to each other, a certified copy of their marriage license is required. The city or town clerk will make an attested copy of this and return it to you. If a marriage license is not available, check with the city or town clerk for more information.

    If the parents are not married to each other, there are very specific requirements for (1) removing husband's information from the record or (2) adding father's information. (These requirements exist regardless of where the birth occurred or who attended the birth.) If this applies to you, contact the city or town clerk for more information.

    When you have the necessary evidence and have completed the attached worksheet, contact the city or town clerk in the community where the birth occurred to schedule an appointment to present the evidence to the clerk. The clerk will type the birth certificate for your signature(s).






Home Birth Worksheet
For Birth Certificates


Please PRINT your responses neatly. Items in BOLD ITALIC appear on your child's birth certificate; the remainder are items collected in accordance with Massachusetts General Law (Ch.111,s.24B). The birth certificate, in addition to being a legal document, is the basis of the state's maternal and perinatal public health database. Answering questions accurately will enable public health program planners to assess public health needs in Massachusetts. Confidential information is not released without the express permission of the Commissioner of Public Health. All data collected from this form is used to compile aggregate statewide data. If you have questions about any of the items on the birth certificate worksheet, please call the Registry at (617) 753-8623. Thank you!




CHILD


PLACE OF BIRTH OCCURRENCE

Street number and street name _______________________________________________

City / Town ______________________________________________________________

CHILD'S DATE OF BIRTH

Month ________________________________ Day ______________ Year 20 ________

Was this a planned home birth?
[    ] Yes
[    ] No

CHILD'S FIRST NAME ____________________________________________________

MIDDLE NAME __________________________________________________________

LAST NAME ____________________________________________________________

GENERATIONAL (e.g. JR) ________________________

SEX OF CHILD
[    ] Female
[    ] Male

PLURALITY
1 [    ] Single
2 [    ] Twin
3 [    ] Triplet
[    ] Other: _____________________________________

BIRTH ORDER
[    ] 1st
[    ] 2nd
[    ] 3rd
[    ] Other: _____________________________________

TIME OF BIRTH

______ ______ : ______ ______ AM PM (circle)





CERTIFIER


NAME OF CERTIFIER

First ___________________________________________________________________

Middle __________________________________________________________________

Last ____________________________________________________________________

Generational (e.g. Jr, 3rd) ________________________

LICENSE NUMBER _____________________________

TYPE OF CERTIFIER
[    ] At-Birth
[    ] Post-Natal
[    ] Certifier Only

TITLE
[    ] MD
[    ] DO
[    ] CNM
[    ] Other RN
[    ] Midwife
[    ] Other (specify):_______________________________________________________

WAS THE CERTIFIER ALSO THE ATTENDANT AT BIRTH?
[    ] Yes
[    ] No

ADDRESS OF CERTIFIER

Number and Street________________________________________________________

City / Town______________________________________________________________

State__________________________________ Zip ______________________________

WAS THE CERTIFIER ALSO THE PRENATAL PROVIDER?
[    ] Yes
[    ] No: Specify name of primary prenatal provider: ________________________________





MOTHER OF THE CHILD


CURRENT - FIRST NAME ________________________________________________

MIDDLE ______________________________________________________________

LAST ________________________________________________________________

MAIDEN SURNAME _____________________________________________________
Last name you were given at your birth or adoption)

HOME TELEPHONE NUMBER (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

DATE OF BIRTH (Month/Day/Year) _______________ / ___ ___ / 19 ___ ___

SOCIAL SECURITY NUMBER ___ ___ ___ - ___ ___ - ___ ___ ___ ___

STATE OR COUNTRY OF BIRTH ___________________________________________
(Your place of birth)

CITY / TOWN OF BIRTH __________________________________________________
(City or Town where you were born)

MOTHER'S RESIDENCE ADDRESS: (Please give the actual address where you live now, including the street name, number, and proper city/town name. Do NOT give the mailing address - if different - in this area. Do not use neighborhood designations or locality names: e.g. 'BOSTON' not 'MATTAPAN'.)

MOTHER'S MAILING ADDRESS:
(If different than your residence address, please write your mailing address below:)

Street Address/ PO Box/ RR Address________________________________________

Mailing City/ Town/ Locality________________________________________________

State/ Country_______________________________ Zip Code ___________________

MOTHER'S MARITAL STATUS: (Although these questions do not actually appear on your child's birth certificate, the information is necessary to register the record legally and properly. Failure to provide accurate marital status information can cause your child's birth certificate to remain unregistered or to be voided later, causing legal difficulties throughout your child's life.)

IS MOTHER MARRIED?
[    ] YES
[    ] NO

If NOT MARRIED, was the mother:
[    ] DIVORCED or [    ] WIDOWED? On what date?_______________________________


If DIVORCED, please give the place of divorce (jurisdiction granting divorce, e.g. County Name):__________________________________________________________________

If NOT MARRIED, and if you live in a different town than where the location of birth is located, you may request that a copy of the birth certificate be kept at your city/town of residence as well. If this applies to you, do you want your child's certificate to be also kept at your residence city/town clerk's office?
[    ] YES
[    ] NO

Massachusetts Law requires that for mothers married at any time between conception and birth, the husband is listed as the father, unless "Denial" statements are completed by the mother and her husband. The biological father may only be added by the completion of an "Acknowledgement of Parentage" statement after "Denial" statements are completed. For unmarried mothers, no father is listed on the birth certificate, unless an "Acknowledgement of Parentage" statement is completed by the mother and the biological father.





Father of the Child


Starred (*) items are only required when an "Acknowledgement of Parentage" will (or is expected to) be completed.

FIRST NAME _________________________________________________________

MIDDLE ______________________________________________________________

LAST ________________________________________________________________

GENERATIONAL (e.g. JR, SR, 3rd)________________________

FATHER'S MOTHER'S MAIDEN SURNAME*
_______________________________________________________________________
Last name of father's mother at time of her birth or adoption)

DATE OF BIRTH (Month/Day/Year) _______________ / ___ ___ / 19 ___ ___

SOCIAL SECURITY NUMBER ___ ___ ___ - ___ ___ - ___ ___ ___ ___

STATE OR COUNTRY OF BIRTH ___________________________________________
(Father's place of birth)

CITY / TOWN OF BIRTH ___________________________________________________
(City or Town where father was born)

FATHER'S RESIDENCE ADDRESS: (When different from the mother)*:

Street Number and Name__________________________ Apartment or Unit # ________

Proper City or Town Name __________________________________________________

County_______________ State/ Country____________________ Zip Code ___________





Confidential Statistical Information

The following items are required to be collected according to Massachusetts' Law (M.G.L. Ch.111, s.24B). This information is kept completely confidential and is used for public health and population statistics, medical research, and program planning, and never released without the express permission of the Commissioner of Public Health. The information you provide lets program planners know where public health services are needed, it gives local school departments numbers by which they can plan for your newborn's future educational needs, and it gives researchers information on which occupations may be hazardous to a newborn's fetal development, to name only a few of the possible data uses. Your occupation is urgently needed in order to compile accurate information about Massachusetts families and their newborns.




Mother of Child

The following questions are about the mother of the child:

Please list the mother's occupation and type of industry over the last year. For "industry" you may list the name of the company.

Examples are:
OCCUPATIONINDUSTRY
HomemakerOwn Home
Computer programmerSoftware Company
Full-time studentCommunity College
CashierStop & Shop


OCCUPATION________________________________________________________

INDUSTRY OR COMPANY________________________________________________

MOTHER'S RACE (Please mark the one category that best describes the mother's race:
    1 [   ] White
    2 [   ] Black
    3 [   ] Asian/Pacific Islander
    4 [   ] American Indian
    5 [   ] Other (specify):______________________________________


MOTHER'S ANCESTRY
(Please mark the one category that best describes the mother's ancestry or ethnic heritage:
    HISPANIC/LATINA
      1 [   ] Puerto Rican
      2 [   ] Dominican
      3 [   ] Mexican
      4 [   ] Cuban
      5 [   ] Colombian
      6 [   ] Salvadoran
      7 [   ] Other Central American
      (specify): __________________________________
      8 [   ] Other South American
      (specify): __________________________________
      9 [   ] Other Hispanic/Latina
      (specify): __________________________________

    ASIAN/PACIFIC ISLANDER
      10 [   ] Chinese
      11 [   ] Vietnamese
      12 [   ] Cambodian
      13 [   ] Asian Indian
      14 [   ] Korean
      15 [   ] Filipino
      16 [   ] Japanese
      17 [   ] Laotian
      18 [   ] Pakistani
      19 [   ] Thai
      20 [   ] Hawaiian
      21 [   ] Other Asian/Pacific Islander
      (specify): __________________________________

    PORTUGUESE SPEAKING
      22 [   ] Cape Verdean
      23 [   ] Brazilian
      24 [   ] Other Portuguese
      (specify): __________________________________

    WEST INDIAN/CARIBBEAN ISLANDER
      25 [   ] Haitian
      26 [   ] Jamaican
      27 [   ] Barbadian
      28 [   ] Other West Indian/Caribbean Islander
      (specify): __________________________________

    AFRICAN/AFRICAN AMERICAN
      29 [   ] African-American/ Afro-American
      30 [   ] Nigerian
      31 [   ] Other African
      (specify): __________________________________

    MIDDLE EASTERN
      32 [   ] Lebanese
      33 [   ] Iranian
      34 [   ] Israeli
      35 [   ] Other Middle Eastern
      (specify): __________________________________

    AMERICAN ANCESTRY
      36 [   ] Native American/ American Indian
      (specify tribe/affiliation): __________________________________
      37 [   ] American


    EUROPEAN and OTHER ancestries
      38 [   ] European
      (specify): __________________________________
      39 [   ] Other
      (specify): __________________________________

MOTHER'S LANGUAGE PREFERENCE
(In what language does the mother prefer to read or discuss health-related materials?


1 [   ] English
2 [   ] American Sign Language (ASL)
3 [   ] Arabic
4 [   ] Cambodian
5 [   ] Cantonese
6 [   ] Haitian Creole
7 [   ] Hmong


8 [   ] Lao
9 [   ] Mandarin
10 [   ] Portuguese
11 [   ] Russian
12 [   ] Spanish
13 [   ] Vietnamese
14 [   ] Other (specify):
________________________________


MOTHER'S EDUCATION
Elementary / Secondary School


a) Please circle the highest grade of elementary or secondary school that the mother completed. If educated outside of the U.S., circle the U.S. grade that is most similar.

b) Please mark the type of diploma received:


[   ] None 1 2 3 4 5 6 7 8 9 10 11 12

[   ] None
[   ] G E D
[   ] High School Diploma


College / University

a) Please circle the number of years that the mother completed. If educated outside of the U.S., circle the number of U.S. years that is most similar.

b) Please mark the highest degree received:


[   ]None   1   2   3   4   Other number of years:____________

[   ]None
[   ]Associate's
[   ]Bachelor's
[   ]Post-graduate


TOBACCO USE:

a) In the year prior to this pregnancy how many cigarettes did you smoke on an average day? Circle one:


[   ]None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
More than 30 (specify):_________________________________


b) During this pregnancy how many cigarettes did you smoke on an average day? Circle one:


[   ]None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
More than 30 (specify):_________________________________


ALCOHOL USE:

a) During this pregnancy, how many drinks (including beer, wine, and cocktails) did you have in an average week? Circle one:


[   ]None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
More than 30 (specify):_________________________________





Father of the Child


The following questions are about the father of the child (please answer whether or not the father is listed on the legal birth certificate):

Please list the father's occupation and type of industry over the last year. For "industry" you may list the name of the company.

OCCUPATION________________________________________________________________

INDUSTRY OR COMPANY______________________________________________________

FATHER'S RACE
(Please mark the one category that best describes the father's race:
    1 [   ] White
    2 [   ] Black
    3 [   ] Asian/Pacific Islander
    4 [   ] American Indian
    5 [   ] Other
    (specify): __________________________________

FATHER'S ANCESTRY
(Please mark the one category that best describes the father's ancestry or ethnic heritage:
    HISPANIC/LATINA
      1 [   ] Puerto Rican
      2 [   ] Dominican
      3 [   ] Mexican
      4 [   ] Cuban
      5 [   ] Colombian
      6 [   ] Salvadoran
      7 [   ] Other Central American
      (specify): __________________________________
      8 [   ] Other South American
      (specify): __________________________________
      9 [   ] Other Hispanic/Latina
      (specify): __________________________________

    ASIAN/PACIFIC ISLANDER
      10 [   ] Chinese
      11 [   ] Vietnamese
      12 [   ] Cambodian
      13 [   ] Asian Indian
      14 [   ] Korean
      15 [   ] Filipino
      16 [   ] Japanese
      17 [   ] Laotian
      18 [   ] Pakistani
      19 [   ] Thai
      20 [   ] Hawaiian
      21 [   ] Other Asian/Pacific Islander
      (specify): __________________________________

    PORTUGUESE SPEAKING
      22 [   ] Cape Verdean
      23 [   ] Brazilian
      24 [   ] Other Portuguese
      (specify): __________________________________

    WEST INDIAN/CARIBBEAN ISLANDER

      25 [   ] Haitian
      26 [   ] Jamaican
      27 [   ] Barbadian
      28 [   ] Other West Indian/Caribbean Islander
      (specify): __________________________________

    AFRICAN/AFRICAN AMERICAN
      29 [   ] African-American/ Afro-American 30 [   ] Nigerian
      31 [   ] Other African
      (specify): __________________________________

    MIDDLE EASTERN
      32 [   ] Lebanese
      33 [   ] Iranian
      34 [   ] Israeli
      35 [   ] Other Middle Eastern
      (specify): __________________________________

    AMERICAN ANCESTRY
      36 [   ] Native American/ American Indian
      (specify tribe/affiliation): __________________________________
      37 [   ] American

    EUROPEAN and OTHER ancestries
      38 [   ] European
      (specify): __________________________________

      39 [   ] Other
      (specify): ___________________________________

FATHER'S LANGUAGE PREFERENCE


1 [   ] English
2 [   ] American Sign Language (ASL)
3 [   ] Arabic
4 [   ] Cambodian
5 [   ] Cantonese
6 [   ] Haitian Creole
7 [   ] Hmong


8 [   ] Lao
9 [   ] Mandarin
10 [   ] Portuguese
11 [   ] Russian
12 [   ] Spanish
13 [   ] Vietnamese
14 [   ] Other (specify):
________________________________


FATHER'S EDUCATION
Elementary / Secondary School


a) Please circle the highest grade of elementary or secondary school that the father completed. If educated outside of the U.S., circle the U.S. grade that is most similar.

b) Please mark the type of diploma received:


[   ] None 1 2 3 4 5 6 7 8 9 10 11 12

[   ] None
[   ] G E D
[   ] High School Diploma


College / University

a) Please circle the number of years that the father completed. If educated outside of the U.S., circle the number of U.S. years that is most similar.

b) Please mark the highest degree received:


[   ]None   1   2   3   4   Other number of years:____________

[   ]None
[   ]Associate's
[   ]Bachelor's
[   ]Post-graduate





Supplemental Survey About Race And Ancestry


Your assistance in this short survey will help the Department of Public Health better understand how the Massachusetts population thinks about race and ethnicity. Your answers will help us to design a better birth certificate and Parent Worksheet that will allow public health workers to develop programs and statistics that more correctly reflect our multi-cultural society.

Were you able to easily identify the mother's and father's race and ancestry from the list presented in the Parent Worksheet?
[   ] Yes
[   ] No

If no:
How does the mother prefer to describe her race?___________her ancestry?___________

How does the father prefer to describe his race?____________his ancestry?___________





Midwife Worksheet

This portion of the worksheet concerns medical statistical information and should be completed by the midwife or other health care professional, if any, that attended the birth or that provided the mother's prenatal care. If there was no health professional that attended the birth or that provided prenatal care, then the mother should complete this information.

PRENATAL CARE
Pregnancy History of Mother


Previous live births: Number still living: ____ ____ Now dead: ____ ____

Date of Last Live Birth: Month ____ ____ /Day ____ ____ /Year ____ ____ ____ ____

Terminations: Total number of induced and spontaneous: ____ ____

Date of Last Termination: Month ____ ____ /Day ____ ____ /Year ____ ____ ____ ____

Date Last Normal Menses Began: Month ____ ____ /Day ____ ____ /Year ____ ____ ____ ____

Date of First Prenatal Visit: Month ____ ____ /Day ____ ____ /Year ____ ____ ____ ____
(If unknown, Month of Pregnancy, e.g. 2nd)
0 [   ] No Prenatal Care

Total Number of Prenatal Visits: ____ ____
00 [   ] None

Total Weight Gained or Lost By Mother: + / - (circle) ____ ____ ____ lbs
Indicate weight loss by circling the minus sign (-). Circle the plus sign (+) or leave blank to indicate a weight gain.

Prenatal Practitioner Types
Check all that apply


1 [   ] MD-Ob/Gyn
2 [   ] MD-Other
3 [   ] D.O.
4 [   ] CNM
5 [   ] Nurse Practitioner

6 [   ] Other RN
7 [   ] Midwife
8 [   ] Physician Asst.
9 [   ] Other (specify):___________
0 [   ] NO PRENATAL CARE


Primary Prenatal Care Site
Check one only


1 [   ] Private Physician's Office
2 [   ] Hospital Clinic
3 [   ] Community Health Center*
4 [   ] Health Maintenance Org. (HMO)
0 [   ] NO PRENATAL CARE
5 [   ] Other*
* Specify site name: __________________________________________


Prenatal Source of Payment
Please complete one response for each part A, B, and C.


A. TYPE OF HEALTH PLAN:
    1 [   ] Non-Managed Care (Indemnity)
    - [   ] Managed Care (please specify type:)
      2 [   ] HMO
      3 [   ] PPO/IPP/IPA
      4 [   ] OTHER (specify): _________________________________
    5 [   ] Free Care
    6 [   ] Self-pay
    7 [   ] Other (specify): __________________________________
    0 [   ] NO PRENATAL CARE
B. NAME OF HEALTH INSURER: __________________________________
C. WERE PRENATAL CARE EXPENSES PAID THROUGH A GOVERNMENT PROGRAM?
[   ] yes    [   ] No

IF YES, PLEASE SPECIFY BELOW:
1 [   ] Commonwealth
2 [   ] Healthy Start
3 [   ] Medicaid / MassHealth
4 [   ] Medicare
5 [   ] Worker's Compensation
6 [   ] Other (specify): __________________________________


Prenatal Tests and Procedures For This Pregnancy
Check all that apply


1 [   ] Amniocentesis (1 to 2 procedures)
2 [   ] Amniocentesis (more than 2 procedures)
3 [   ] Assisted reproductive technology (alternative methods of conception)
4 [   ] Cerclage
5 [   ] Fertility Drug
6 [   ] Hospitalization (prenatal, for this pregnancy)
7 [   ] Ultrasound (1 to 2 procedures)
8 [   ] Ultrasound (more than 2 procedures)
9 [   ] Other (specify other prenatal tests and procedures including AFP, Triple Test, CVS, etc.):

___________________________________________________________________

___________________________________________________________________
0 [   ] No Prenatal Tests or Procedures


Risk Factors For This Pregnancy
Check all that apply


1 [   ] AIDS/HIV Positive
2 [   ] Acute or Chronic Lung Disease
3 [   ] Anemia (hct < 30, hgb < 10)
4 [   ] Cardiac Disease
5 [   ] Diabetes (Gestational)
6 [   ] Diabetes (Other)
7 [   ] Eclampsia
8 [   ] Genital Herpes
9 [   ] Hydramnios/Oligohydramnios
10 [   ] Hemoglobinopathy
11 [   ] Hypertension (Chronic)
12 [   ] Hypertension (Pregnancy Related)
13 [   ] Hepatitis B Carrier (HBsAg positive)
14 [   ] Incompetent Cervix
15 [   ] Lupus Erythematosus
16 [   ] Previous Infant with Birth Defect
17 [   ] Previous Infant 4000+ grams
18 [   ] Previous Preterm or SGA Infant
19 [   ] Renal Disease
20 [   ] Rh sensitization
21 [   ] Rubella infection during pregnancy
22 [   ] Seizure disorder
23 [   ] Sexually Transmitted Disease (specify): __________________________________
24 [   ] Sickle Cell Anemia
25 [   ] Uterine Bleeding
26 [   ] Weight gain/loss inappropriate for mother
27 [   ] Other (specify other risk factors such as tobacco or substance abuse, social, domestic and environmental risk factors, etc.)

___________________________________________________________________

___________________________________________________________________
00 [   ] No risk factors for this pregnancy


Labor and Delivery

Method of Delivery
Check all methods used or attempted:


1 [   ] Vaginal
2 [   ] Vaginal after prior c-section (VBAC)
3 [   ] Forceps
4 [   ] Vacuum
5 [   ] Primary c-section
6 [   ] Repeat c-section


Birthweight lbs/oz or grams: _____ lbs _____ oz / ______ grams

Clinical Estimate of Gestation: _____ _____ weeks

Apgar Scores: 1 min. _____ 5 min. _____ 10 min. _____

Complications of Labor and Delivery


1 [   ] Abruptio Placenta
2 [   ] Anesthetic complications
3 [   ] Breech/malpresentation
4 [   ] Cephalopelvic disproportion
5 [   ] Cord prolapse
6 [   ] Dysfunctional labor
7 [   ] Febrile ( > 100 degrees F. Or 38 degrees C.)
8 [   ] Fetal distress
9 [   ] Meconium, moderate to heavy
10 [   ] Other excessive bleeding
11 [   ] Placenta previa
12 [   ] Precipitous labor ( < 3 hours)
13 [   ] Prolonged labor ( > 20 hours )
14 [   ] Prolonged second stage ( > 3 hours)
15 [   ] Rupture of membrane - Premature ( > 12 hours)
16 [   ] Rupture of membrane - Prolonged ( > 24 hours)
17 [   ] Seizures during labor
18 [   ] Other (specify): _______________________________________________________

__________________________________________________________________________

__________________________________________________________________________
00 [   ] No complications during labor and delivery


Labor and Delivery Procedures


1 [   ] Electronic Fetal Monitoring (external)
2 [   ] Electronic Fetal Monitoring (internal)
3 [   ] Hysterectomy
4 [   ] Induction of labor
5 [   ] Pharmacologic inhibition of labor (tocolysis)
6 [   ] Steroid for neonatal pulmonary maturity
7 [   ] Stimulation / Augmentation of labor
8 [   ] Tubal ligation
9 [   ] Other (specify): ________________________________________________________

__________________________________________________________________________

__________________________________________________________________________
0 [   ] No complications during labor and delivery


Delivery Source of Payment
Indicate the expected source of payment for this delivery:


A. TYPE OF HEALTH PLAN:
    1 [   ] Non-Managed Care (Indemnity)
    - [   ] Managed Care (please specify type:)
      2 [   ] HMO
      3 [   ] PPO/IPP/IPA
      4 [   ] Other (specify): __________________________________
    5 [   ] Free Care
    6 [   ] Self-pay
    7 [   ] Other (specify): __________________________________
    0 [   ] NO PRENATAL CARE
B. NAME OF HEALTH INSURER: __________________________________
C. WERE PRENATAL CARE EXPENSES PAID THROUGH A GOVERNMENT PROGRAM?
[   ] yes    [   ] No

IF YES, PLEASE SPECIFY BELOW:
1 [   ] Commonwealth
2 [   ] Healthy Start
3 [   ] Medicaid / MassHealth
4 [   ] Medicare
5 [   ] Worker's Compensation
6 [   ] Other (specify): __________________________________


Neonatal Conditions and Procedures

Method of Delivery
Check all methods used or attempted:


1 [   ] Anencephalus
2 [   ] Hydrocephalus
3 [   ] Microcephalus
4 [   ] Spina Bifida / Meningocele
5 [   ] Other central nervous system anomalies (specify):

____________________________________________________________
6 [   ] Patient ductus arteriosus
7 [   ] Ventricular septal defect
8 [   ] Other heart malformations (specify):

____________________________________________________________
9 [   ] Other circulatory anomalies (specify):

____________________________________________________________
10 [   ] Other respiratory anomalies (specify):

____________________________________________________________
11 [   ] Rectal atresia / stenosis
12 [   ] Tracheoesophageal fistula / esophageal atresia
13 [   ] Umbilical hernia
14 [   ] Omphalocele / gastroschisis
15 [   ] Other gastrointestinal anomalies (specify):

____________________________________________________________
16 [   ] Hypospadia
17 [   ] Malformed genitals (specify):

____________________________________________________________
18 [   ] Renal agenesis
19 [   ] Hydronephrosis (prenatal diagnosis only)
20 [   ] Other urogenital anomalies (specify):

____________________________________________________________
21 [   ] Cleft Lip
22 [   ] Cleft Palate
23 [   ] Developmental dysplasia of the hips (specify):

____________________________________________________________
24 [   ] Adactyly
25 [   ] Polydactyly
26 [   ] Syndactyly
27 [   ] Club Foot
28 [   ] Diaphragmatic hernia
29 [   ] Limb reduction defects
30 [   ] Other musculoskeletal anomalies (specify):

____________________________________________________________
31 [   ] Birthmark / Storkbite / Mongolian spot
32 [   ] Other integumental anomalies (specify):

____________________________________________________________
33 [   ] Trisomy 21 (Down Syndrome)
34 [   ] Other chromosomal anomalies (specify):

____________________________________________________________
35 [   ] Multisystem anomalies / syndromes (specify):

____________________________________________________________
36 [   ] Other (specify):

____________________________________________________________

____________________________________________________________

____________________________________________________________
00 [   ] No observed congenital anomalies / no birth defects


Abnormal Conditions of the Newborn


1 [   ] Acidosis
2 [   ] Anemia
3 [   ] Congenital infection
4 [   ] Cyanosis
5 [   ] Erb's palsy, or
6 [   ] Other birth trauma
7 [   ] Fetal Alcohol Syndrome
8 [   ] Hyaline Membrane Disease / RDS
9 [   ] Hypotonia
10 [   ] Hypoxia
11 [   ] Intracranial hemorrhage
12 [   ] Jaundice (bilirubin > 10)
13 [   ] Meconium aspiration syndrome
14 [   ] Positive toxicology screen
15 [   ] Seizures
16 [   ] Sepsis
17 [   ] Tachypnea
18 [   ] Other (specify):________________________________________________________

__________________________________________________________________________

__________________________________________________________________________
00 [   ] No abnormal conditions


Neonatal Procedures


1 [   ] Assisted ventilation ( < 30 min.)
2 [   ] Assisted ventilation ( > / = 30 min.)
3 [   ] Circumcision
4 [   ] Intubation
5 [   ] Phototherapy
6 [   ] Surfactant replacement
7 [   ] Vaccine (specify):

Type: [   ] Hep B - Date given:____________ Manufacturer:____________ Lot#:______

Type: [   ] HBIG -- Date given:____________ Manufacturer:____________ Lot#:______

_____________________________________________________________________
8 [   ] Other neonatal procedures (specify):

_____________________________________________________________________

_____________________________________________________________________
0 [   ] No neonatal procedures


Was the Child transferred to a hospital after delivery?

[   ] No
If Yes, transferred to:
[   ] Out-of-state hospital (0080)
[   ] Massachusetts hospital (specify):

_________________________________________________________________________


Is Mother Breastfeeding (or intending to breastfeed)?

[   ] Yes
[   ] No


As time of this report, child is:

[   ] Living
[   ] Dead
If dead, Date of Death: Month_____ _____ / _____ _____ / _____ _____ _____ _____

Pediatric Provider - Individual practitioner's name

First______________________ Last____________________ Title/Degree________________
Or health agency name and site

Organization :________________________________________________________________

Site (if applicable): ____________________________________________________________
Location

City/Town: __________________________ State (if no MA): ________________ Zip: _______





MoonDragon's Pregnancy Information Index
MoonDragon's Pregnancy Information & Survival Tips






MoonDragon's Womens Health Index

| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z |






Health & Wellness Index





AROMATHERAPY: ESSENTIAL OILS DESCRIPTIONS & USES


Allspice Leaf Oil
Angelica Oil
Anise Oil
Baobab Oil
Basil Oil
Bay Laurel Oil
Bay Oil
Benzoin Oil
Bergamot Oil
Black Pepper Oil
Chamomile (German) Oil
Cajuput Oil
Calamus Oil
Camphor (White) Oil
Caraway Oil
Cardamom Oil
Carrot Seed Oil
Catnip Oil
Cedarwood Oil
Chamomile Oil
Cinnamon Oil
Citronella Oil
Clary-Sage Oil
Clove Oil
Coriander Oil
Cypress Oil
Dill Oil
Eucalyptus Oil
Fennel Oil
Fir Needle Oil
Frankincense Oil
Geranium Oil
German Chamomile Oil
Ginger Oil
Grapefruit Oil
Helichrysum Oil
Hyssop Oil
Iris-Root Oil
Jasmine Oil
Juniper Oil
Labdanum Oil
Lavender Oil
Lemon-Balm Oil
Lemongrass Oil
Lemon Oil
Lime Oil
Longleaf-Pine Oil
Mandarin Oil
Marjoram Oil
Mimosa Oil
Myrrh Oil
Myrtle Oil
Neroli Oil
Niaouli Oil
Nutmeg Oil
Orange Oil
Oregano Oil
Palmarosa Oil
Patchouli Oil
Peppermint Oil
Peru-Balsam Oil
Petitgrain Oil
Pine-Long LeafOil
Pine-Needle Oil
Pine-Swiss Oil
Rosemary Oil
Rose Oil
Rosewood Oil
Sage Oil
Sandalwood Oil
Savory Oil
Spearmint Oil
Spikenard Oil
Swiss-Pine Oil
Tangerine Oil
Tea-Tree Oil
Thyme Oil
Vanilla Oil
Verbena Oil
Vetiver Oil
Violet Oil
White-Camphor Oil
Yarrow Oil
Ylang-Ylang Oil
Aromatherapy
Healing Baths For Colds
Aromatherapy
Herbal Cleansers
Using Essential Oils


AROMATHERAPY: HERBAL & CARRIER OILS DESCRIPTIONS & USES


Almond, Sweet Oil
Apricot Kernel Oil
Argan Oil
Arnica Oil
Avocado Oil
Baobab Oil
Black Cumin Oil
Black Currant Oil
Black Seed Oil
Borage Seed Oil
Calendula Oil
Camelina Oil
Castor Oil
Coconut Oil
Comfrey Oil
Evening Primrose Oil
Flaxseed Oil
Grapeseed Oil
Hazelnut Oil
Hemp Seed Oil
Jojoba Oil
Kukui Nut Oil
Macadamia Nut Oil
Meadowfoam Seed Oil
Mullein Oil
Neem Oil
Olive Oil
Palm Oil
Plantain Oil
Plum Kernel Oil
Poke Root Oil
Pomegranate Seed Oil
Pumpkin Seed Oil
Rosehip Seed Oil
Safflower Oil
Sea Buckthorn Oil
Sesame Seed Oil
Shea Nut Oil
Soybean Oil
St. Johns Wort Oil
Sunflower Oil
Tamanu Oil
Vitamin E Oil
Wheat Germ Oil





HELPFUL RELATED MOONDRAGON NUTRITION BASICS LINKS

  • MoonDragon's Nutrition Basics Index
  • MoonDragon's Nutrition Basics: Amino Acids Index
  • MoonDragon's Nutrition Basics: Antioxidants Index
  • MoonDragon's Nutrition Basics: Enzymes Information
  • MoonDragon's Nutrition Basics: Herbs Index
  • MoonDragon's Nutrition Basics: Homeopathics Index
  • MoonDragon's Nutrition Basics: Hydrosols Index
  • MoonDragon's Nutrition Basics: Minerals Index
  • MoonDragon's Nutrition Basics: Mineral Introduction
  • MoonDragon's Nutrition Basics: Dietary & Cosmetic Supplements Index
  • MoonDragon's Nutrition Basics: Dietary Supplements Introduction
  • MoonDragon's Nutrition Basics: Specialty Supplements
  • MoonDragon's Nutrition Basics: Vitamins Index
  • MoonDragon's Nutrition Basics: Vitamins Introduction


  • NUTRITION BASICS ARTICLES

  • MoonDragon's Nutrition Basics: 4 Basic Nutrients
  • MoonDragon's Nutrition Basics: Avoid Foods That Contain Additives & Artificial Ingredients
  • MoonDragon's Nutrition Basics: Is Aspartame A Safe Sugar Substitute?
  • MoonDragon's Nutrition Basics: Guidelines For Selecting & Preparing Foods
  • MoonDragon's Nutrition Basics: Foods That Destroy
  • MoonDragon's Nutrition Basics: Foods That Heal
  • MoonDragon's Nutrition Basics: The Micronutrients: Vitamins & Minerals
  • MoonDragon's Nutrition Basics: Avoid Overcooking Your Foods
  • MoonDragon's Nutrition Basics: Phytochemicals
  • MoonDragon's Nutrition Basics: Increase Your Consumption of Raw Produce
  • MoonDragon's Nutrition Basics: Limit Your Use of Salt
  • MoonDragon's Nutrition Basics: Use Proper Cooking Utensils
  • MoonDragon's Nutrition Basics: Choosing The Best Water & Types of Water





  • RELATED MOONDRAGON HEALTH LINKS & INFORMATION

  • MoonDragon's Nutrition Information Index
  • MoonDragon's Nutritional Therapy Index
  • MoonDragon's Nutritional Analysis Index
  • MoonDragon's Nutritional Diet Index
  • MoonDragon's Nutritional Recipe Index
  • MoonDragon's Nutrition Therapy: Preparing Produce for Juicing
  • MoonDragon's Nutrition Information: Food Additives Index
  • MoonDragon's Nutrition Information: Food Safety Links
  • MoonDragon's Aromatherapy Index
  • MoonDragon's Aromatherapy Articles
  • MoonDragon's Aromatherapy For Back Pain
  • MoonDragon's Aromatherapy For Labor & Birth
  • MoonDragon's Aromatherapy Blending Chart
  • MoonDragon's Aromatherapy Essential Oil Details
  • MoonDragon's Aromatherapy Links
  • MoonDragon's Aromatherapy For Miscarriage
  • MoonDragon's Aromatherapy For Post Partum
  • MoonDragon's Aromatherapy For Childbearing
  • MoonDragon's Aromatherapy For Problems in Pregnancy & Birthing
  • MoonDragon's Aromatherapy Chart of Essential Oils #1
  • MoonDragon's Aromatherapy Chart of Essential Oils #2
  • MoonDragon's Aromatherapy Tips
  • MoonDragon's Aromatherapy Uses
  • MoonDragon's Alternative Health Index
  • MoonDragon's Alternative Health Information Overview
  • MoonDragon's Alternative Health Therapy Index
  • MoonDragon's Alternative Health: Touch & Movement Therapies Index
  • MoonDragon's Alternative Health Therapy: Touch & Movement: Aromatherapy
  • MoonDragon's Alternative Therapy: Touch & Movement - Massage Therapy
  • MoonDragon's Alternative Health: Therapeutic Massage
  • MoonDragon's Holistic Health Links Page 1
  • MoonDragon's Holistic Health Links Page 2
  • MoonDragon's Health & Wellness: Nutrition Basics Index
  • MoonDragon's Health & Wellness: Therapy Index
  • MoonDragon's Health & Wellness: Massage Therapy
  • MoonDragon's Health & Wellness: Hydrotherapy
  • MoonDragon's Health & Wellness: Pain Control Therapy
  • MoonDragon's Health & Wellness: Relaxation Therapy
  • MoonDragon's Health & Wellness: Steam Inhalation Therapy
  • MoonDragon's Health & Wellness: Therapy - Herbal Oils Index







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    MOONDRAGON'S REALM - WEBSITE DIRECTORY


    A website map to help you find what you are looking for on MoonDragon.org's Website. Available pages have been listed under appropriate directory headings.