Generated Narrative

questionnaire: http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death

status: completed

subject: Patient - Decedent Fetus (Fetus Not Named). Generated Summary: Medical Record Number: 9932702 (USUAL); UNK ; gender: female; birthDate: 2019-01-09; deceased: true

source: Patient - Mother (Carmen Teresa Lee). Generated Summary: Medical Record Number: 9992702 (USUAL); Carmen Teresa Lee (OFFICIAL), Carmen Teresa Santos (MAIDEN); gender: female; birthDate: 1986-02-15

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: 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-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]
*	No

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-dob

text: What is your date of birth?

Answers

-	Value[x]
*	1986-02-15

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-territory

text: or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas

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]
*	9th through 12th grade; no diploma

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: 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 is the father's date of birth?

Answers

-	Value[x]
*	1984-02-27

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: receive-wic

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

Answers

-	Value[x]
*	No

item

linkId: mothers-height

text: What is your height?

item

linkId: mothers-height-inches

text: Inches

item

linkId: mothers-prepregnancy-weight

text: lbs

Answers

-	Value[x]
*	180 [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