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Initial Patient Registration for Newborns
Less than 1 month old

Step 1



Which hospital was your child born in?


Pregnancy

Did you have any of the following problems during pregnancy?







Did you receive any medications during pregnancy other than Prenatal vitamins?



Birth




Was your baby Jaundiced before leaving the hospital?


Did your baby have any other complications?





If child was a boy, was he circumcised?

Do you know how much he / she weighed on the day of discharge from hospital?






Approximately how many times a day is your baby having bowel movements?

111 Otis Smith Drive, Clarksville, Tennessee 37043 ♦ Phone: 931-553-6666 ♦ Fax 931.553.6681 ♦ Email: info@rainbowkidsclinic.com