Dear parents,

Thank you for filling in these details of the outcome of your pregnancy. As you know this information will be helpful for us for our continuing audit and improve our performance. You can be assured that this information will be completely confidential and will not be utilized for any commercial activity. We wish you all the best and really appreciate the time taken to give us these details.

Mother's full name  *
Scan ID  *
Email ID  *
What was the outcome of Pregnancy  *

Date of Delivery *
Where did you deliver *
How did you deliver?  *

What is the sex of the Baby?  *

Name of the Baby (Optional)
What was the baby's birth weight?
( after 5 min)
Did the baby need treatment in the special
baby care unit

If yes-please specify
At what age did the baby come home at
- days on
Did the baby have any problems?

If yes, what was it?
Tests during the course of the pregnancy?

Did the mother / the baby have any
illnesses during the course of the
pregnancy? -if so, please comment:
Illnesses during the course

Time Period