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  *Name:
  *Date of Birth:
  *Medications taken during pregnancy:  Antibiotics
 Anti-depressants
 Sleep aids
 Thyroid/synthroid
 Steroidal creams
 Cancer Medications
 Nasal sprays
 vitamins/ Homeopathic Remedies
 Other
 None of the above
  *Infections/ Illness (Mom):  Throat
 Vaginal herpes
 Strep infections
 Blood/Skin disorders/ infections
 Emotional trauma
 Chest/Lung infactions
 Colds/Sinuses
 Traumatic incidents/ accidents
 Other
 None of the above
  *Episodes:  Spotting
 Position of Placenta
 Cramping
 Other
 None of the above
  *Tests:  External Ultrasounds
 Amniocentesis
 CT Scan
 MRI
 Internal Ultrasound
 Surgical procedure
 Anesthesia
 Other
 None of the above
  *Birth/ Labor:  Natural
 C-Section
 Breech
 Epidural
 Pitocin
 Difficult
 Trauma to Mom
 Other
 None of the above
  *Delivery:  Hypoxic event
 Forceps/ Vacume delivery
 Umbilical cord around baby's neck
 Baby cried upon birth
 Dr. delayed delivery
 Other
 None of the above
  *Post Natal:  Vaccines
 Antibiotics usage
 Ear infections
 Digestive problems
 Immune problems
 Breathing problems
 Concentration/ Focus/ Learning issues
 Behavioral issues
 Other
 None of the above
  *Weeks of Pregnancy:
  *Mom's number of child given birth:

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