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354
Name of Patient: Name of Patient: Name of Patient:
____________________________________________________ ____________________________________________________ ____________________________________________________
Case No.: ________________ Gender: ____________________ Case No.: ________________ Gender: ____________________ Case No.: ________________ Gender: ____________________
Name of Mother: Name of Mother: Name of Mother:
____________________________________________________ ____________________________________________________ ____________________________________________________
Address: ____________________________________________ Address: ____________________________________________ Address: ____________________________________________
Date of Delivery: _____________________________________ Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Gender of Baby: ______________________________________ Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Time of Delivery: _____________________________________ Time of Delivery: _____________________________________ Time of Delivery: _____________________________________
Type of Delivery: _____________________________________ Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Pediatrician: _________________________________________ Pediatrician: _________________________________________ Pediatrician: _________________________________________