Child Birth Certificate Texas Template Form – Fill Out and Use This PDF

Am / Pm

Single / Twin / Triplets / Quadruplets / Quintuplets

VS-109.1 REV 2/2005

MOTHER’S RESIDENCE ADDRESS

Residence Address				Apartment Number			State/Foreign Country				County
City/Town/Location					Zip Code / Extension			Inside City Limits?
								□ Yes	□ No
MOTHER’S MAILING ADDRESS	(If same as residence address, LEAVE THIS SECTION BLANK)
Mailing Address			Apartment Number				State/Foreign Country
City/Town/Location					Zip Code / Extension			Inside City Limits?
								□ Yes	□ No

□ Yes □ No

□ Yes □ No

Mother’s Education

□8th grade or less

□9th – 12th grade, no diploma

□High School graduate or GED completed

□Some College credit, but no degree

□Associate degree (e.g., AA, AS)

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

Is Mother of Hispanic Origin?

□No, not Spanish / Hispanic / Latina

□Yes, Mexican, Mexican American, Chicana

□Yes, Puerto Rican

□Yes, Cuban

□Yes, other Spanish / Hispanic / Latina

Specify______________

What is Mother’s Race?

□ White			□ Vietnamese
□ Black/African American			□ Other Asian________
□ American Indian/Alaska Native			□ Native Hawaiian
(Name of the enrolled or principal tribe)			□ Guamanian or
			Chamorro
□			□ Samoan
	Asian Indian
□ Chinese			□ Other Pacific Islander
□ Filipino			Specify
□ Japanese			□ Other
□ Korean			□ Unknown

Father’s Education

□8th grade or less

□9th – 12th grade, no diploma

□High School graduate or GED completed

□Some College credit, but no degree

□Associate degree (e.g., AA, AS)

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

Is Father of Hispanic Origin?

□No, not Spanish / Hispanic / Latino

□Yes, Mexican, Mexican American, Chicano

□Yes, Puerto Rican

□Yes, Cuban

□Yes, other Spanish / Hispanic / Latino

Specify______________

What is Father’s Race?

□ White			□ Vietnamese
□ Black/African American			□ Other Asian
□ American Indian/Alaska Native			□ Native Hawaiian
	(Name of the enrolled or principal tribe)		□ Guamanian or
			Chamorro
□ Asian Indian			□ Samoan
□ Chinese			□ Other Pacific Islander
□ Filipino			Specify
□ Japanese			□ Other
□ Korean			□ Unknown

Prenatal Care □ Yes □ No □ Unknown

Date of First Visit ____/____/______

Date of Last Visit ____/____/______

Total Number of Prenatal Visits for this Pregnancy: ________

Date Last Normal Menses Began ___/___/_____

Pregnancy History

Live births now living (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____

Live births now dead (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____

Date of last live birth: ____/______

MM YYYY

Number of other pregnancy outcomes (Include fetal losses of any gestational age. If this was a multiple delivery, include all fetal losses delivered before this infant in the pregnancy.

If none enter “0”.): _____

Date of last other pregnancy outcome: ____/______

MM YYYY

Infections Present and/or Treated During Pregnancy

□ Gonorrhea	□ Hepatitis B
□ Syphilis	□ Hepatitis C
□ Chlamydia	□ None of the above

Source of Prenatal Care	(check all that apply)
□ None	□ Midwife
□ Hospital Clinic	□Other, Specify __________________
□ Public Health Clinic	□ Unknown
□ Private Physician

Risk Factors in this Pregnancy (check all that apply)

Diabetes

□Prepregnancy (diagnosis prior to this pregnancy)

□Gestational (diagnosis in this pregnancy)

Hypertension

□Prepregnancy (chronic)

□Gestational (PIH, preeclampsia)

□Eclampsia

□Previous preterm birth

□Other previous poor pregnancy outcome (includes perinatal death, small-for- gestational age/intrauterine growth restricted birth)

□Pregnancy resulted from infertility treatment

□Fertility-enhancing drugs, artificial insemination or intrauterine insemination

□Assisted reproductive technology

□Mother had a previous cesarean delivery

If yes, how many?_____

□Antiretrovirals administered during pregnancy or at delivery

□None of the above

HIV Test

HIV test done Prenatally	□ Yes	□ No	□ Unknown
HIV test done at Delivery	□ Yes	□ No	□ Unknown

Obstetric Procedures (check all that apply)

□Cervical cerclage

□Tocolysis

External cephalic version

□Successful □ Failed

□None of the above

Characteristics of Labor & Delivery

(check all that apply)

□Induction of labor

□Augmentation of labor

□Non-vertex presentation

□Steroids (glucocorticoids) for fetal lung maturation received by mother prior to delivery

□Antibiotics received by mother during labor

□Chorioamnionitis or maternal temperature > = 38 degrees C or

100.4degrees F

□Moderate/heavy meconium staining of the amniotic fluid

□Fetal intolerance of labor was such that one or more of the following actions was taken: in-utero resuscitative measures, further assessments, or operative delivery

□Epidural or spinal anesthesia during labor

□None of the above

Maternal Morbidity – Complications associated with Labor & Delivery

□Maternal transfusion

□Third or forth degree perineal laceration

□Ruptured uterus

□Unplanned hysterectomy

□Admission to intensive care unit

□Unplanned operating room procedure following delivery

□None of the above

Onset of Labor (check all that apply)

□Premature Rupture of the Membranes [prolonged > =12 hours]

□Precipitous Labor [< 3 hours]

□Prolonged Labor [> = 20 hours]

□None of the above

Method of Delivery
Was delivery with forceps attempted but unsuccessful?
□ Yes	□ No	□ Unknown
Was delivery with vacuum extraction attempted but unsuccessful?
□ Yes	□ No	□ Unknown
Fetal presentation at birth		□ Other, _________________________
□ Cephalic	□ Breech
Final route and method of delivery
□ Vagina/Spontaneous		□ Vagina/Forceps □ Vagina/Vacuum
If cesarean, was a trial of labor attempted?			□ Cesarean
□ Yes	□ No	□ Unknown
Child’s Health Information
Birth Weight	________ Grams, or ________LB. ________OZ.

Obstetric Estimate of Gestation (completed weeks): _________

Child’s Sex: □ Male □ Female □ Not yet determined

Apgar Score: at 5 min:_______; (if less than 6) at 10 min:_______

Abnormal Conditions of the Newborn (check all that apply)

□Assisted ventilation required immediately following delivery

□Assisted ventilation required for more than six hours

□NICU admission

□Newborn given surfactant replacement therapy

□Antibiotics received by the newborn for suspected neonatal sepsis

□Seizure or serious neurologic dysfunction

□Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention)

□None of the above

Congenital Anomalies of the Newborn (check all that apply)

Was Infant Transferred within 24 hours of Delivery?

□No □ Yes, Specify Facility _________________

Is Infant Living at Time of Report?

□Yes □ No

Is Infant Being Breastfed at Discharge?

□Yes □ No

□Anencephaly

□Meningomyelocele/Spina bifida

□Cyanotic congenital heart disease

□Congenital diaphragmatic hernia

□Omphalocele

□Gastroschisis

□

□Cleft palate alone

□Down syndrome

□Karyotype confirmed

□Karyotype pending

□Suspected chromosomal disorder

□Karyotype confirmed

□Karyotype pending

Hepatitis B Immunization given?

□ Yes □ No

	□ Hypospadias
□ Cleft lip with or without Cleft palate	□ None of the above