Profile Submission Form April 20, 2023April 20, 2023 by Nicole C Reason for visit:Reason for visit: Parent’s or Mother’s DemographicsName First Last Nickname/Alt Email Address Upload Profile PhotoMax. file size: 64 MB.Date of Birth MM slash DD slash YYYY Phone NumberAlternative Phone Number (optional)Address Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Referred By Insurance Plan Member ID# Subscriber / Policy Holder on Insurance PlanMyselfPartner/SpouseMy parentUpload DocumentMax. file size: 64 MB.OB/Midwife Name or Practice Name OB/Midwife Phone Number Pharmacy Name Pharmacy Phone Number Who referred you to us? Baby’s DemographicsName Baby First Name Baby Last Name Baby Date of Birth or Expected Due Date MM slash DD slash YYYY Gestational Age Wks. days Birth Weight lbs. oz. Discharge Weight lbs. oz. Discharge Date MM slash DD slash YYYY Current or Most Recent Weight lbs. oz. Date of Current/Recent Weight MM slash DD slash YYYY Baby Insurance Plan Baby Member ID# Subscriber / Policy Holder on Insurance PlanBabyMyselfMy Partner/SpouseUpload DocumentMax. file size: 64 MB.Pediatrician’s Name or Practice Name Pediatrician’s Phone NumberCo-Parent/Spouse/Partner’s Demographics (If applicable)Co-Parent/Spouse/Partner’s Name Co-Parent/Spouse/Partner’s Date of Birth MM slash DD slash YYYY Medical InformationBirth Location Type of birthVaginalVBACVacuum AssistedForcepsCesareanAre you (check all options that apply): Breastfeeding? Pumping? Supplementing? How many times do you nurse per day? How many pumping sessions per day? How much do you yield per day? How many bottles per day? How much pumped milk? Total amount of supplement per day How much donor milk? How much formula? How many wet diapers per day? How many soiled diapers per day? Do you have any allergies? If so, please list them. Do you take any medications? If so, please list them. Does Baby take any medications? If so, please list them. Parent Well BeingDo you have a history of depression and/or anxiety or are you currently experiencing symptoms of anxiety or depression? Yes No Do you feel safe within your home? Yes No Do you want to speak to me without your partner present? Yes No Have you ever had to seek help with a safety concern (women’s shelter or via the police)? Yes No Is your partner supportive of your goals as you have shared them with me? Yes No If I need to contact you confidentially, specifically what route should I use?TextPhoneEmailPaperSecure messagingEdinburgh Postpartum Scale