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Pregnancy Outcome

We maintain complete records of pregnancy outcomes that include not only births, but also miscarriages, stillbirths, and therapeutic abortions. This helps us maintain a donor's family limit, track health and medical information for donors, recipients, and children, and provide ongoing services to families after children are born.

This report concerns your most recent pregnancy with TSBC samples. If you are unsure about a question or prefer not to answer, just leave it blank or enter "unsure" / "withheld." We'll contact you if we need clarification. We guarantee complete confidentiality. No identifying information will be released. If you prefer to mail or fax the form, click here for a pdf version or simply fill out the form below, print it, and fax or mail it in. Thank you for your time.

* = Required Field

Recipient's name
*
Partner's name
(if applicable)

Have you moved?
New address
New home phone number
New cell phone number

Donor #
*
TSBC pregnancy #


Pregnancy Outcome:
Live birth
Singleton
Twins
Triplets

Date of delivery (mm/dd/yyyy)
At weeks

Pregnancy loss
Spontaneous miscarriage
At weeks
Miscarriage #

Therapeutic abortion
At weeks
Miscarriage #

Stillbirth
At weeks

Other




Was the fetus normal? Yes   No  

Pregnancy normal?
Yes   No
(please identify the primary problems)
Abnormal fetus position
Bleeding
Placenta problem
High blood pressure
Gestational Diabetes
Pre-eclampsia
Toxemia
Other:
Problems at delivery?
Yes   No
(please identify the primary problems)
Breech
Hemorrhage
Pitocin induction/augmentation
Fetal Distress
Other:
Delivery setting
(final location)
Home
Birthing Center
Hospital birthing center/room
Labor/delivery room
Operating room
Other
Type of delivery
Spontaneous vaginal
Induced vaginal
Suction
Forceps
C-section
Other



Child #1 name
Female     Male
Apgar score #1
Apgar score #2
Infant Health
Excellent
Good
Fair
Poor
Weight lbs ozs
Length in.
Birth/genetic defects or other problems


Child #2 name
Female     Male
Apgar score #1
Apgar score #2
Infant Health
Excellent
Good
Fair
Poor
Weight lbs ozs
Length in.
Birth/genetic defects or other problems


Child #3 name
Female     Male
Apgar score #1
Apgar score #2
Infant Health
Excellent
Good
Fair
Poor
Weight lbs ozs
Length in.
Birth/genetic defects or other problems

Interested in purchasing sibling inventory? Yes   No
- Buy ASAP to guarantee availability. See our catalog of sibling inventory or call us directly to inquire.



Questions/Comments:


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last updated: 05.29.2008


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