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  • CS Form No. 212 Revised Personal Data Sheet - New

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    DhanNie Cenita
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    Newborn Tag

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    032117 CS Form No. 212 Revised Personal Data Sheet_new

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    Newborn Tag

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    34 views2 pages

    CS Form No. 212 Revised Personal Data Sheet - New

    Uploaded by

    DhanNie Cenita
    Newborn Tag

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    ZONE MEDICAL INTERVENTION HOSPITAL ZONE MEDICAL INTERVENTION HOSPITAL

    Binatagan, Ligao City Binatagan, Ligao City


    Patient’s Name : _____________________________________________ Patient’s Name : _____________________________________________
    Mother’s Name: _____________________________________________ Mother’s Name: _____________________________________________
    Date of Birth : _____________________________________________ Date of Birth : _____________________________________________
    Time of Birth : ____________________________________________ Time of Birth : ____________________________________________
    Type of Delivery: ___________________________________________ Type of Delivery: ___________________________________________
    Anthropometric measurement: Anthropometric measurement:
    Head circ = ____ cm Length = ____ cm Head circ = ____ cm Length = ____ cm
    Chest circ = ____ cm Weight = ____ cm Chest circ = ____ cm Weight = ____ cm
    Abd circ = ____ cm Abd circ = ____ cm
    Pediatrician : _____________________________________________ Pediatrician : _____________________________________________

    Hi. I’m BABY GIRL ___________________________. Hi. I’m BABY BOY ___________________________.
    My mommy’s name is _____________________________ and My mommy’s name is _____________________________
    she delivered me last _________________________ at and she delivered me last _________________________ at
    ______________ via _____________. Her doctor’s name is ______________ via _____________. Her doctor’s name is
    Dr. _____________________________ while mine is Dr. _____________________________ while mine is
    Dr.________________________. Dr.________________________.
    My head circumference measures ______ My head circumference measures ______
    cm, my chest circumference measures ______ cm, cm, my chest circumference measures ______ cm,
    and my abdominal circumference measures _______ and my abdominal circumference measures
    cm. I’m ______ cm tall and I weigh ___________ grams, _______ cm. I’m ______ cm tall and I weigh ___________
    can you believe that?  grams, can you believe that? 

    Hi. I’m BABY GIRL ___________________________. Hi. I’m BABY BOY ___________________________.
    My mommy’s name is _____________________________ and My mommy’s name is _____________________________ and
    she delivered me last _________________________ at she delivered me last _________________________ at
    ______________ via _____________. Her doctor’s name is ______________ via _____________. Her doctor’s name is
    Dr. _____________________________ while mine is Dr. _____________________________ while mine is
    Dr.________________________. Dr.________________________.
    My head circumference measures ______ cm, my My head circumference measures ______ cm, my
    chest circumference measures ______ cm, and my chest circumference measures ______ cm, and my
    abdominal circumference measures _______ cm. I’m abdominal circumference measures _______ cm. I’m
    ______ cm tall and I weigh ___________ grams, can you ______ cm tall and I weigh ___________ grams, can you
    believe that?  believe that? 
    Hi. I’m BABY GIRL Hi. I’m BABY BOY
    ______________________. My mommy’s ______________________. My mommy’s
    name is _________________________ and name is _________________________ and
    she delivered me last she delivered me last
    _______________________ at ______________ _______________________ at ______________
    via _____________. Her doctor’s name via _____________. Her doctor’s name
    is Dr. __________________________ while is Dr. __________________________ while
    mine is Dr.________________________. mine is Dr.________________________.
    My head circumference My head circumference
    measures _______ cm, my chest measures _______ cm, my chest
    circumference measures ______ circumference measures ______
    cm, and my abdominal cm, and my abdominal
    circumference measures _______ circumference measures _______
    cm. I’m ______ cm tall and I weigh cm. I’m ______ cm tall and I weigh
    ___________ grams, can you believe ___________ grams, can you believe
    that?  that? 

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