Expectant Mothers and Baby Information Sheet

Expectant Mommy’s Name

Given Name Middle Name Last Name
Sasha Dominique Panes Tan

Age: 23 Civil Status: Single

Date of Birth: December 23, 1999 Place of Birth: Cebu City
Religion: Roman Catholic Citizenship: Filipino
Philhealth #: 18-025359281-6 Tin #:
Telephone #: Contact #: 0967 907 2734

Address:
Sitio Bioborjan, Brgy. Rizal, Surigao City

Height: WT Before Pregnancy:

Last Menstrual Period: Expected Date of Delivery: Curent Age of Gestation:
(LMP) 06/19/2022 (EDD) 03/26/2023 (AOG)

Age you had Menstrual Cycle: 10 years old Date and Year of First Menstrual
Period:
What is your Menstrual Cycle: How many days of Menstruation: 4
Regular Irregular days
No. of Pregnancy: 1 No. of Live Birth >
Allergies:
Illnesses:
Pregnancy Tests Done: (Indicate Dates) 06/30/2022
Supplementary Vitamins Taken During Pregnancy:
Do you smoke? Yes No Do you drink Alcohol? Yes No
Any Complications During Pregnancy?
None Yes:
_____________________________________________________________________________
Medical Insurance Provider HMO:
Attending OB: Contact #:
Attending Pedia: Contact #:
Family History:

Baby’s Information
Baby’s Name
Gender Given Name Middle Name Last Name
Girl Azaria Zyaire Finn Li Tan Medalla

If in case I’m a Boy: Xin Ashton Maeve Tan Medalla

Daddy’s Information
Given Name Middle Name Last Name
Ronald Jhon Bayang Medalla

Age: 26 Civil Status: Single

Date of Birth: January 16, 1997
Religion: Roman Catholic
Philhealth #: 18-250654537-5
Telephone #:
Place of Birth: Cabangahan, Tago, Surigao
Del Sur
Citizenship: Filipino
Tin #: 498-095-802-000
Contact #: 0927 589 0691

IN CASE OF EMERGENCY, PLEASE CONTACT:

Name Contact #
Ronald Jhon B. Medalla 0927 589 0691
Melisa P. Tan 0975 476 9409
Cerlina B. Medalla 0981 066 2933