Generated Narrative

questionnaire: http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-mothers-live-birth

status: completed

subject: BabyG Quinn. Generated Summary: Medical Record Number: 9932702 (USUAL); Baby G Quinn ; gender: female; birthDate: 2019-02-12; 1

source: Patient - Mother (Jada Ann Quinn). Generated Summary: Social Security number: 132225986 (USUAL), Medical Record Number: 1032702 (USUAL); Jada Ann Quinn (OFFICIAL), Jada Ann King (MAIDEN); Phone: 1-(404)555-1212, jadaann.quinn@example.com; gender: female; birthDate: 1985-01-15

item

linkId: mother-current-legal-name

text: What is your current legal name?

item

linkId: mother-first-name

text: First

item

linkId: mother-middle-name

text: Middle

item

linkId: mother-last-name

text: Last

item

linkId: child-name

text: What will be your baby's legal name (as it should appear on the birth certificate)?

item

linkId: child-first-name

text: First

item

linkId: child-middle-name

text: Middle

item

linkId: child-last-name

text: Last

item

linkId: mother-address

text: Where do you usually live - that is - where is your household/residence located?

item

linkId: mother-nbr-street

text: Complete number and street (do not enter rural route numbers)

item

linkId: mother-city

text: City, Town, or Location

item

linkId: mother-county

text: County

item

linkId: mother-state

text: State (or U.S. Territory, Canadian Province)

item

linkId: mother-zip

text: Zip Code

item

linkId: inside-city-limits

text: Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?

Answers

-	Value[x]
*	Yes

item

linkId: mother-mail

text: What is your mailing address

item

linkId: mother-mail-same

text: Same as residence [Go to next question]

item

linkId: mother-mail-nbr-street

text: Complete number and street

item

linkId: mother-mail-city

text: City, Town, or Location

item

linkId: mother-mail-state

text: State (or U.S. Territory, Canadian Province)

item

linkId: mother-mail-zip

text: Zip Code

item

linkId: mother-dob

text: What is your date of birth?

Answers

-	Value[x]
*	1985-01-15

item

linkId: mother-birthplace

text: In what State, U.S. territory, or foreign country were you born? Please specify one of the following:

item

linkId: mother-birthplace-state

text: State

item

linkId: mother-education

text: What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).

Answers

-	Value[x]
*	Doctorate Degree or Professional Degree

item

linkId: mother-ethnicity

text: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.

item

linkId: mother-shl

text: Are you Spanish/Hispanic/Latina

item

linkId: mother-race

text: What is your race? (Please check one or more races to indicate what you consider yourself to be).

item

linkId: mother-race-category

text: Race categories

item

linkId: mother-detailed-race

text: Extended race codes

item

linkId: receive-wic

text: Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?

Answers

-	Value[x]
*	Yes

item

linkId: infertility-treatment

text: Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)

answer

value: true

item

linkId: drugs-ai-ii

text: If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?

item

linkId: art-ivf-gift

text: If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?

item

linkId: mothers-height

text: What is your height?

item

linkId: mothers-height-feet

text: Feet

item

linkId: mothers-height-inches

text: Inches

item

linkId: mothers-prepregnancy-weight

text: lbs

Answers

-	Value[x]
*	145 [lb_av]

item

linkId: mothers-smoking

text: How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.

item

linkId: mothers-smoking-3-months-prior

text: Three months before pregnancy

item

linkId: mothers-smoking-trimester-1

text: First three months of pregnancy

item

linkId: mothers-smoking-trimester-2

text: Second three months of pregnancy

item

linkId: mothers-smoking-trimester-3

text: Third trimester of pregnancy

item

linkId: mother-prior-name

text: What name did you use prior to your first marriage?

item

linkId: mother-prior-first-name

text: First

item

linkId: mother-prior-middle-name

text: Middle

item

linkId: mother-prior-last-name

text: Last

item

linkId: married-conception

text: Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]

Answers

-	Value[x]
*	true

item

linkId: father-current-legal-name

text: What is the current legal name of your baby's father?

item

linkId: father-first-name

text: First

item

linkId: father-middle-name

text: Middle

item

linkId: father-last-name

text: Last

item

linkId: father-dob

text: What the father's date of birth?

Answers

-	Value[x]
*	1983-09-27

item

linkId: father-birthplace

text: In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:

item

linkId: father-birthplace-state

text: State

item

linkId: father-education

text: What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).

Answers

-	Value[x]
*	Doctorate Degree or Professional Degree

item

linkId: father-ethnicity

text: Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.

item

linkId: father-shl

text: Is the father Spanish/Hispanic/Latina

item

linkId: father-race

text: What is the father's race? (Please check one or more races to indicate what he considers himself to be).

item

linkId: father-race-category

text: Race categories

item

linkId: parents-ssn

text: Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.

item

linkId: mother-ssn

text: What is your Social Security Number?

item

linkId: father-ssn

text: What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.

item

linkId: baby-ssn

text: Do you want a Social Security Number issued for your baby? [If yes, please sign request below

Answers

-	Value[x]
*	false

item

linkId: informant-name

text: If other than the mother, what is the name of the person providing information for this worksheet?

item

linkId: informant-first-name

text: First

item

linkId: informant-last-name

text: Last

item

linkId: informant-relationship

text: What is your relationship to the baby's mother?

Answers

-	Value[x]
*	Other relative