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3
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Date of Birth:
(Child)
Does your child have cerebral palsy or brain damage?
Yes
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How many weeks pregnant were you at time of delivery?
Baby's birth weight?
How did mom deliver?
Vaginal
Forceps/Vacuum
C/S
Was the baby's heart rate dropping prior to birth?
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No
Was the baby breathing after birth?
Yes
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Apgar scores, if known:
Did your baby require a breathing tube?
Yes
No
Did your baby have an MRI, Ultrasound, or CT of the brain?
Yes
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What were the results?
Normal
Abnormal
How long did your baby remain in the hospital?
If you baby went home on medications, which ones?
Anything to add?
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