Hospital of Birth

Enter the name of the hospital where the child was born. You can enter up to 90 characters.

County

Select the name of the county where the child was born. Select Other if the child was not born in Ohio.

Other

If you selected Other in the County field, enter the name of the county where the child was born. You can enter up to 50 characters. This field is required when you enter Other.

Location Details

Enter the hospital's address or a description of the location. You can enter up to 100 characters.

Birth Weight

Enter the child's weight at birth in either pounds and ounces or in kilograms and grams.

Birth Length

Enter the child's length in inches.

APGAR Score at 1 minute

Enter the APGAR score from the medical records.

A score is given for each sign at one minute and five minutes after the birth. The score reflects activity (muscle tone), pulse, grimace (reflex irritability), appearance (skin color), and respiration.  If there are problems with the baby an additional score is given at 10 minutes. A score of 7-10 is considered normal, a score of 4-7 might require some resuscitative measures, and a score of 3 and below requires immediate resuscitation

Gestational Term

Enter the number of weeks the mother was pregnant before delivery.

Mother's First Prenatal Visit

Select the month in which the mother made her first prenatal visit.

Duration of Labor

Enter the number of hours the mother was in labor before delivering the child. Use the format HH:MM.

Multiple Births

Indicate whether the mother had twins, triplets, and so on.

Delivery Type

Indicate whether the birth was vaginal or cesarean.

If Cesarean, Explain

If you selected cesarean in the Delivery Type field, explain the circumstances for this procedure. You can enter up to 300 characters.

Position

Select the child's position at birth.

Heart Murmur at Birth

Indicate whether the medical staff detected a heart murmur when the child was born.

If Yes, Explain

If you selected Yes in the Heart Murmur at Birth field, explain the recommended treatment. You can enter up to 300 characters.

Complications at Birth

Describe any complications that occurred during the child's birth. You can enter up to 300 characters.

Complications after Birth

Describe any complications that occurred after the child's birth. You can enter up to 300 characters.

Blood Type

Select the child's blood type.

RH Factor

Select the child's RH factor.

PKU

Select the child's PKU.

Sickle Cell Disease

Indicate whether the newborn was tested for sickle cell disease.

Galactosemia

Indicate whether the newborn was tested for galactosemia.

Other

Indicate whether other tests were conducted on the newborn.

Results

Describe the other tests conducted on the newborn and results.

Hypothyroidism

Indicate whether the newborn was tested for hypothyroidism.

Other

Describe any additional tests performed on the newborn.

Results

Enter the results of any tests listed in the Other field.