Database on Newborn Health and Birth Defects Center Name Baby’s Hospital Record No. Birth Defects (BD) Form Mother’s Hospital Record No. NNPD Number 1 2 3 4 5 6 7 8 9 Birth Defects 1. Basic information: Mother’s Name Date of Delivery * Time of Delivery (24 hr format) Mother’s Age (Years Completed) Father’s Age (Years Completed) Parental consanguinity * Baby’s Gender * i. ii. iii. iv. v. vi. d m h Y/N Male vii. viii. Birth weight (g) ix. Head Circumference x. Mode of delivery * xi. Multiple birth xii. Gestation xiii. Delivery attended by xiv. Outcome xv. Autopsy (in case of still birth) * 2. History of birth Defects: m y y h / Female y m / y m Ambiguous cm Vaginal / Cesarean section / Single / Twin / Triplet / Higher order (in weeks) Instrumental Doctor / Nurse / ANM / Midwife Alive / Died / Still Birth – Fresh/ Still Birth – Macerated Y / N i. Previous termination of pregnancy for malformation ii. Previous Still birth iii. Previous spontaneous abortion(s) 3. d Y / N Y/N If Yes, Please describe Yes; if any birth defect found Y/N Y/N Type of birth defect(s): S/N Type of Birth Defect Full description Code ICD-10 C or P # i. ii. iii. iv. v. 4. Additional information/investigation if any 5. Photographs taken Y / N Name of the professional completed the physical form Date: # C = Confirmed, P = Possible * Mandatory Fields Supported by WHO-SEARO and CDC Atlanta Attach Photo (if yes selected) Physician / Nurse / Other
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