Prenatal Record - National Archives and Records Administration

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REPRODUCTIVE HISTORY
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RICORD PRI!GNAMCII!S IN CHRONOLOGICAL ORD.R
PREGNANCY ORDER: I 2 3 4 s
I. DATE OF TERMINATION
OF PREGNANCY
2. GESTATION (W••i&s)
3. LIVEBORN (Yu '"No)
4. D & C AFTER
MISCARRIAGE
5. SEX (M or F)
6. NAME OF CHILD
COMPLICATIONS OF
7. PREGNANCY
8. INDUCED LABOR
(Y•• or No)
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9. DURATION OF LABOR
(How•)
Vaginal
TYPE
10.
DELIVERY OF Snech ·-•
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II. BIRTH WEIGHT ..
(U.•• - 0..)
12. PLACI! OF BIRTH IIKOIID CITY AND MAMa 0, HOSPITAL IN SPACI! II!LOW
ll. !-rg~~~LITIES
. '
14. NAME OF FATHER ~·
15. RACE OF FATHER
DATE OF DEATH
16. ..
OF CHILD
17. PLACE OF DEATH
18. CAUSE OF DEATH
19.
INFORMANT (lrhrw •.....:•
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12. PLACE OF BIRTH (R«or;! Cux llllll N-o( ,.pil!ll
I. ,I
2.
3.
4.
5.
IF MORE THAN S PREGNANCIES, USE ANOTH!tt FORM.
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Public Heelth Sw.ice
II.A.36
OB-2
Reproduced at the National Archives