|WV - DHHR - BPH - OMCFH - Birth Score|
GUIDELINES page 3 of 4
V. INFORMATION ABOUT SELECTED BIRTH SCORE FACTORS:
1. Previous Pregnancies: Count all pregnancies prior to this one. Include ectopic pregnancies, miscarriages and terminations.
2. Feeding Intentions: Score is based on the mother's original intent. Did mother plan to breast-feed or bottle-feed?
3. Nicotine use during pregnancy: If the response is yes, select all forms of nicotine used during pregnancy and fill in all bubbles that apply.
4. Add the score of the seven factors and enter the total. This is the baby's BIRTH SCORE.
VI. INFORMATION ABOUT DEVELOPMENTAL RISK FACTORS:
Congenital Abnormalities: If the infant has one or more of the following congenital abnormalities select from the list below ONE (1) condition that best describes the infantís risk for developmental delay and insert the number corresponding to that risk in the block provided.
If there is an identified Congenital Abnormality or one or more Yes responses noted on the Developmental Screen, the infant is at-risk for Developmental Delay.
01. Down Syndrome (Trisomy 21)
02. Other Trisomies (13,18)
03. Sex Chromosome Abnormalities (Examples include Fragile X, XXX, XYY, XXY)
04. Other Chromosomal Abnormalities (Examples include Cri Du Chat;
06. Grade III or IV intracranial hemorrhages
07. Birth weight less than 10% for gestational age (SGA)
08. Microcephaly less that 5%
09. Neural tube defects (Examples include spina bifida, encephalocele)
10. Hydrocephaly greater than 95%
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