BIBLIOGRAPHIC INPUT SHEET TEMPORARY Patterns of mortality ...

Appendix 1 365
INTER-AMERICAN INVESTIGATION OF MORTALITY
IN CHILDHOOD
Confidential Death - page 4
Name of child
Date of
birth
Serial no.
Date of
Sex Age at
death death _yrs. _._moS.____days hro,
DATA OBTAINED FROM HOSPITAL, CLINIC OR PHYSICIAN
51. Abnormal None Edema Hyper, Albumi- Convul- Hyper- Anemia Threatened Placenta
tension nuria ions emesis abortion previa
conditions of
pregnancy 03 1 0] 0 0 0 0 0
52. Conditions Nona German T b c Syphi- Operation: reason, findings Trauma, specify
unrelated to measles puIm. lie
C
pregnancy 13 C
Other, specify
Other, specify
53. Delivery Spontane- Manipu- Forceps CesrianiAiesthe. Sedation Oter pecify 5 Length of 55. Single or
g estatio multiple birth
OUs 0 lation 3 0 0 sia 0 C
DATA ON CHILD (age in completed months in first line)
56. Age jAt birth
57. Weight
58. Nutritional status
59. DATA ON NEWBORN FROM RECORD
General state: Good 0 Fair 0 Poor 0 Genitals:
Activity:
Normal 0 Abnormal 0 Extremities:
First cry _ min. First breathing m__min. Skin, color
Normal
Normal
0
03
Abnormal
Abnormal
03 Extremities
03Time
Movements: Normal 0
Muscular tone: Increased 03 Normal 03 Abnormal 0
Cyanosis:
General
Decreased 03 Jaundice: Yes -- No
Head - Size: Increased 0 Normal 0 Decreased 0 Hemorrhagic signs: Yes 0' No 0
Shape: Normal 0 Abnormal
Cephalohematoma 03 Lacerations
Eyes, nose, ears, mouth
Neck - Rigidity: Yes 0 No 0 Masses [
Chest:
First voiding _ hrs. First bowel movement hra.
First feeding _ hrs. Type
Acceptance 0 Rejection 03
Progress:
0
[
03
0
Infection signs:
Lacerations: Yes 03 No 0
Edema
Breathing: Normal 0 Irregular 03
Secretion
Abdominal: Masses 0 Hernia 03
Congenital anomalies:
0
60. PRINCIPAL FINDINGS IN HOSPITAL AND CLINICS, PRIOR TO ILLNESS LEADING TO DEATH
61. Source of Private r
information: Hospital 03 Clinic 03 M. D. 0 1Othe 0j Date -______Interviewer