buprenorphine in pregnancy register - maternity hospital

Buprenorphine In Pregnancy Register - Maternity Hospital - The Women's

This form is to be used by maternity services.

If you do not work for a maternity hospital, then please return to the main Buprenorphine in Pregnancy Register page.

* denotes a mandatory field

*Maternity hospital Angliss HospitalBairnsdale HospitalBallarat Base HospitalBendigo HospitalBox Hill HospitalCentral Gipsland HospitalDandenong HospitalFrankston HospitalGeelong HospitalGoulburn Valley HospitalHamilton Base HospitalLatrobe Regional HospitalMercy Hospital for WomenMonash Medical CentreNorthern HospitalRoyal Women's HospitalSunshine HospitalSwan Hill HospitalWangaratta Base HospitalWerribee Mercy HospitalWest Gippsland HospitalWondonga HospitalOther Hospital not on list *Prescriber email *Client's first name initial (First initial only) *Cilent's surname initials (First two initials only) *Client's DOB Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarApMayJunJulAugSepOctNovDec *Buprenorphine commenced ... before pregnancy  during pregnancy   *Buprenorphine dose at time of delivery mg Other substance use: Heroin No  Yes   Benzodiazepines No  Yes   Marijuana No  Yes   Ecstasy No  Yes   Amphetamines No  Yes   Tobacco No  Yes   Alcohol No  Yes   Other Birth Details: Birth Outcome Miscarriage  Still Birth  Neonatal Death  Live Birth   Type of Birth Normal  Instrumental  Caesarian   Neonatal Details: Sex of Baby Male  Female  Indeterminant   Gestation at Birth weeks Birth Weight g Head Circumference cm Apgar 1 min 012345678910 5 min 012345678910 Length of hospital stay days Neonatal Abstinence scored No  Yes   Medication for Neonatal Abstinence Sydrome? No  Yes   Breastfed at time of discharge No  Yes   Congenital Abnormalities No  Yes   Specify