Data Input Page

Your first name: First name of user required.
Your last name: Last name of user required.
Relationship to patient: Self Parent/Guardian Other

Please specify your relationship to the patient:"

Your email address: Please provide a proper email address. Your phone number: Please provide a proper phone number (ex. 111-555-000).

Patient's First Name: Patient's first name required.
Patient's Middle Name (if any):
Patient's Last Name: Patient's last name required.
Patient's Birthdate:
Patient sex: Patient's state

FOR THE TIME BEING ONLY PA COUNTIES AVAILABLE. LONG TERM REACH GOAL IS THAT BASED ON THE STATE SELECTED A LIST OF APPROPRIATE COUNTIES/PARISHES WILL BE AVAILALBE.

Patient's county

Check any that apply immediately before, during, or after the pregnancy for the biological mother.

Maternal injury.

Please provide information about the injury.

Hospitalization during pregnancy.

Please provide information about the hospitalization.

X-Rays during pregnancy.

Please provide information about the x-rays.

Special diet during pregnancy?
What medications were taken during pregnancy?

Please list biological mother's meds during pregnancy.

Mother's age at conception:
Did mother have previous pregnancies? no yes

Please list number of previous pregnancies including miscarraiges.

Did mother receive prenatal care during this pregnancy? no yes
During the pregnancy, was the baby: Very active active Rather quiet
Were there any unusual changes in the baby's activity level during pregnancy? no yes

Check any that were relevant for the biological mother during pregnancy.

Emotional problems	Infections	Premature labor
Rashes	Bed-rest	Toxemia
Difficulty in Conception	Anemia	Gained more than 35 pounds
Excessive Swelling	Vaginal bleeding	Measles/German measles
Excessive nausea/Vomiting	Flu	High blood pressure
Kidney disease	Strep throat	Threatened miscarriage
Rh incompatibility	Headaches	Severe cold
Urinary problems	Other virus	Other Issue