Birth information form

Name of female

Female’s date of birth

Treatment:

Pregnancy:

Have you had a karyotype analysis made on the fetus(es):

a) Amniotic fluid sampling:

Yes

No

b) Chorionic villus biopsy :

Yes

No

If yes, was the result normal:

Yes

No

If the amniocentesis / chorionic villus sampling scan was not normal, please describe:

Did the pregnancy end by miscarriage

Yes

No

If yes: Miscarriage before gestation week 12:

Yes

No

Miscarriage in gestation week 12 – 20:

Yes

No

Miscarriage in gestation week 20 -28:

Yes

No

Ectopic pregnancy:

Yes

No

Birth:

Date of birth:

Hospital, country:

Gender:

Boy

Girl

Weight:

g

Length:

cm

In which gestation week did you give birth:

Induction of labor:

Natural birth

Induced labour

Was the child delivered via a Caesarian section:

Yes

No

Was the child born using suction/forceps

Yes

No

Is the child healthy:

Yes

No

If no, what is wrong:

If you feel like it, please write us a little greeting:

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If you gave birth to more than one (1) child, please complete a form for each child. Thank you for your help.

Birth registration form

Pregnancy and birth form

Pregnancy:

Birth:

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