Pregnancy Outcome Report

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. For more information regarding the importance of reporting all pregnancies and outcomes, please click Pregnancy Outcome Reporting.

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 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 #

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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   No Answer

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Pregnancy normal? Yes   No   No Answer	(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   No Answer	(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

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Child #1 name

Female     Male
Apgar score #1
Apgar score #2
Infant Health
Excellent
Good
Fair
Poor
Weight lbs oz
Length inches
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 oz
Length inches
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 oz
Length inches
Birth/genetic defects or other problems

Interested in purchasing sibling inventory? Yes   No   No Answer
- 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: 04.19.2009 form submission edits: 10.14.2009