Submitter information
Submitter's Name: First
Middle Initial
Last
First Name required
Last Name required
Relationship to baby/patient:
Relationship required
Address: Street and number
Address Required
City
State
or Country
Zip code
or Postal Code
City Required
State or Country Required
Zip Code or Postal Code required
Telephone number (Include Area or Country Code):
Telephone required
E-mail address
Invalid email format
Confirm Email
Email does not match
Patient information Information needed
Year of birth
City of Birth
Incorrect data
State or Country
Birth weight
Unit required
Incorrect data
Gestational age (weeks)
Sex:
Gender required
Incorrect data
Recent Height:
Unit required
Incorrect data
Recent Weight:
Unit required
Incorrect data
Age at Measurement
Unit required
Incorrect data
Health problems:
Physical limitations:
Learning problems:
Behavior problems:
Miscellaneous Information :
Age at above assessment
Incorrect data
Publication Information
If this infant's story has been published in a medical journal, lay publication,
or at another website, please complete the following where applicable:
Category:
Title (of article or book):
Author(1) Last Name
First
Name
Middle
Initial
Author(2) Last Name
First
Name
Middle
Initial
Author(3) Last Name
First
Name
Middle
Initial
Author(4) Last Name
First
Name
Middle
Initial
Author(5) Last Name
First
Name
Middle
Initial
Author(6) Last Name
First
Name
Middle
Initial
Please check if there are more than six authors:
Journal Name
Publisher
Year
Volume
Incorrect data
Issue
Page number(s)
Incorrect data
Additional note
URL (if applicable)
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