Pregnancy, Birth & Newborn History Form PARENT/GUARDIAN DETAILSName Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Preferred NameOccupation*Postal Address* Address Suburb State Postcode Date of Birth DD MM YYYY GenderMaleFemaleMobile Phone*Home PhoneWork PhoneEmail*We will send you a copy of your responses for your records Private Health?*YesNoFund Name*Member Number*EMERGENCY CONTACT PERSONEmergency Contact Name* First Last Phone*Relationship to you*WHO MAY WE THANK FOR REFERRING YOU?Source Recommendation from Friend/Family/Colleague Facebook Website Google/Internet Signage Other Name of Referrer*YOUR BABYChild's Name First Last Child's Date of Birth DD MM YYYY AgeMother's Name First Last PREGNANCYHow many children do you haveWhat was the term of this pregancy?weeksDuring pregnancy did you have any of the followingFallsYesNoDetailsMotor Vehicle AccidentsYesNoDetailsNear miss MVAYesNoDetailsHigh Blood PressureYesNoDetailsDiabetesYesNoDetailsAnaemiaYesNoDetailsMorning SicknessYesNoDetailsIndigestionYesNoDetailsSeizuresYesNoDetailsSwollen anklesYesNoDetailsThyroid ProblemsYesNoDetailsHeart ProblemsYesNoDetailsBack PainYesNoDetailsAbnormal BleedingYesNoDetailsWere you HospitalizedYesNoDetailsAny Other Illness or Injury? During pregnancy did you use any of the followingTobaccoYesNoDetailsAlcoholYesNoDetailsNon-Prescribed DrugsYesNoDetailsPrescription MedicationYesNoDetailsMedicationReason DetailsMedicationReason Over the Counter MedicationYesNoLABOUR & DELIVERYLength of labour from first regular contractions to birthHoursLength of second stage (pushing stage) of labourHoursHospital BirthYesNoHome BirthYesNoMidwife AssistedYesNoVaginal DeliveryYesNoPlanned C-SectionYesNoEmergency C-SectionYesNoWas Birth Induced (Pitocin)YesNoForceps DeliveryYesNoVacuum ExtractionYesNoAnaesthesia AdministeredYesNoFetal DistressYesNoMeconium StainingYesNoHead PresentationYesNoFace PresentationYesNoBreech PresentationYesNoBABY'S CONDITION IMMEDIATELY AFTER BIRTHApgar Scores (out of 10)at 1 minuteat 5 minutes Baby's Crying Immediately After BirthCried StronglyWeak CryDid not cry immediatelyAfter how long did baby start to cryminutesBaby's Colour Pink all over Blue Face Blue Hands/Feet Baby's ActivityArms and legs actively movingFloppy babyIntensive Care RequiredYesNoDays in neonatal Intensive care unitVaccines administeredMedication at BirthBaby MeasurementsBirth Weight (lb/kg)Birth Length (cm)Baby home on Day NEWBORN HISTORYHow many hours does you baby sleep between feeds?During the dayAt night Does you baby go to sleep easily?YesNoDoes your baby have a preferred sleep position?YesNoDoes baby cry if you change his sleep position?YesNoDoes baby have feeding difficulties?YesNoIs baby being breast fed?YesNoFor how long was baby breast fed?week/monthsDoes baby have a one sided breast-feeding preference?YesNoPreferred BreastLeftRightIs baby Formula fed?YesNoWhich formula or other milk source?Does baby frequently spit-up after feeding?YesNoDoes your baby cry a lot?YesNoFor how many hours each day?Does baby pass a lot of intestinal gas?YesNoDoes baby have a preferred head position?YesNoDoes baby frequently arch his /her head and neck backwards?YesNoDoes baby cry or become irritable during nappy change?YesNoHas baby ever had a fever?YesNoHas baby had any falls?YesNoHas baby been in a car accident or near miss?YesNoHas baby had any trauma?YesNoHas your baby been vaccinated?YesNoDo you have any other concerns you wish to discuss?YesNoPlease advise
