Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-B
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Birth:
[] Male
[] Female child of ________________ ______________________ Race: ____________
Family Name Mother's Given Name
Hospital Number _____________ _______________ Attending Physician _______________
Mother Infant Mother
Time ________________________________________ Attending Physician _______________
a.m. p.m. Day Month Year Infant
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Maternal History:
Mother's age ________________ Blood type ___________ RH ______________
Total # previous pregnancies ____ # Premature ____ # Neonatal deaths ____ # Now living ____ Maternal disease:
Complications of this pregnancy:
Drugs taken during pregnancy:
Prenatal S.T.S.: Date _________ Results _________ If ever positive, give summary of treatment:
Maternal chest X-ray: Date _______ Results ________ HIV: Date _______ Results ________
Hep B: Date _______ Results ______ Other Significant lab. Results _____________________
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Present Delivery:
Duration of gestation _______ Mo. Of pregnancy prenatal care started _________ EDC _______
Labor induced? ____________ How? ______________ Why? ___________________________
Duration of labor: 1st stage _________ 2nd stage _________ 1st or 2nd stage oxytocic __________
Membrane ruptured: Spontaneously _____ artificially _____ # hours before delivery _________
Presentation _________________ Position ______________ Type delivery ________________
Reasons if operative _____________________________________________________________
Analgesia (type and time before delivery) __________________ Total Amount _____________
Anesthesia (type and duration before labor) ________________ Amount ___________________
Placenta: Normal ___________________ Abnormal (describe) _________________________
Complications of delivery:
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Infant Record:
Breathed Spontaneously (time) _________________ Resuscitation required? _______________
Eye prophylaxis ______ Blood type ______ RH _____ P K U Date _______ Results _________
T4 Date _______ Results _______ Sickle(s) Hgb. Date ________ Results __________________
HIV Screen Date ___________ Results ______________
APGAR Score ___________ One Minute; ____________ Five minutes
Describe complications (tone, color, cry, injuries, malformations)
Birth weight __________ Birth length _________ Chest circ. __________ Head circ. _________
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Neonatal Course in Hospital:
Feeding: Breast only _________ Formula only _________ Breast and Formula ____________
Content of formula __________________
Progress in nursery (include weight gains or losses, feeding or sleeping difficulties, diarrhea, respiratory distress, rashes, or other significant details)
Discharge: Date _________ Weight ________ Length _______ General condition ___________
Impressions and Recommendations:
Signature ________________________
Date ________________________
Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-B