Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Any family history of: *

Antibiotics

Anti-depressants

Cancer medications

Nasal sprays

Sleep aids

Steroidal creams

Thyroid or synthroid

Vitamins or homeopathic Remedies

Other

None of the above

Infections/ Illness (Mom): *

Blood/skin disorders/infections

Chest/Lung infactions

Colds/Sinuses

Emotional trauma

Strep infections

Throat

Traumatic incidents/ accidents

Vaginal herpes

Other

None of the above

Episodes: *

Spotting

Position of Placenta

Cramping

Other

None of the above

Tests: *

Amniocentesis

Anesthesia

CT Scan

External Ultrasounds

Internal Ultrasound

MRI

Surgical procedure

Other

None of the above

Birth/ Labor: *

Breech

C-Section

Difficult

Epidural

Natural

Pitocin

Trauma to Mom

Other

None of the above

Delivery: *

Baby cried upon birth

Doctor delayed delivery

Forceps or vacuum delivery

Hypoxic event

Umbilical cord around baby's neck

Other

None of the above

Post Natal: *

Antibiotics usage

Behavioral issues

Breathing problems

Concentration, focus, or learning issues

Digestive problems

Ear infections

Immune problems

Vaccines

Other

None of the above