My Advocates

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Subject

Does your child have cerebral palsy or brain damage?
Yes No 

How many weeks pregnant were you at time of delivery?

Baby’s birth year?(required)

Baby’s birth state? (required)

How did mom deliver?
Vaginal Forceps/Vacuum Cesarean Section 

Was the baby’s heart rate dropping prior to birth?
Yes No 

Was the baby breathing after birth?
Yes No 

Apgar scores, if known.

Did your baby require a breathing tube?
Yes No 

Did your baby have seizures, shakes or tremors within 48 hours after delivery?
Yes No 

Was your baby transferred to the Neonatal Intensive Care Unit?
Yes No 

Did your baby have an MRI, Ultrasound or CT of the brain?
Yes No 

What were the results?
Normal Abnormal 

How long did your baby remain in the hospital?

If your baby went home on medications, which ones?

Your Message