NEWBORN New Patient Questionnaire

Child's Name

Date of Birth

Parent/Guardian #1 Name

Date of Birth

Occupation

Parent/Guardian #2 Name

Date of Birth

Occupation

Who are this child's legal guardians?

PREGNANCY AND BIRTH

What was the baby's due date?

What was the birth weight?

What hospital was the child born in?

If yes, Formula Name?

If yes, please explain

If yes, please explain

If yes, please explain

If yes, please explain

If yes, please explain

Were there any other events during the baby's hospitalization that you think we should know about?

FAMILY HISTORY

Below is a list of potential medical problems or chronic diseases that may affect people in your family. Please circle any conditions in the family and give additional details as you are able.

Asthma

Other details or information

Other Lung problem

Other details or information

High blood pressure

Other details or information

Heart disease or heart attack

Other details or information

High cholesterol

Other details or information

Heart defect at birth

Other details or information

Celiac disease

Other details or information

Crohn's disease or ulcerative colitis

Other details or information

Liver Disease

Other details or information

Child onset diabetes

Other details or information

Adult onset diabetes

Other details or information

Thyroid disease

Other details or information

Recurrent bladder infections

Other details or information

Kidney problems

Other details or information

Anemia

Other details or information

Drug allergies

Other details or information

Food allergies

Other details or information

Cancers of any kind

Other details or information

Seizure disorder

Other details or information

Autism

Other details or information

Mental handicap

Other details or information

Need as child for speech physical, or occupational therapy

Other details or information

Eczema

Other details or information

Recurrent skin infection

Other details or information

Depression

Other details or information

Anxiety

Other details or information

Other psychiatric disorder

Other details or information

Broken bones

Other details or information

Other bone or muscle problem

Other details or information

Diabetes

Other details or information

Other Endocrine problem

Other details or information

Period/menstrual problems

Other details or information

Use of alcohol or drugs

Other details or information

Other Medical problems

Other details or information

SAFETY / ENVIRONMENT

Does anyone the child lives with or sees on a regular basis smoke (inside or outside)

Yes No

What year was your home built?

Are you concerned your child may be exposed to lead?

Yes No

Is there a working smoke alarm on each floor of your home?

Yes No

Do you have any concerns about the safety of your home?

Yes No

Explain

PLEASE LIST ANY OTHER QUESTIONS/CONCERNS YOU HAVE OR OTHER IMPORTANT INFORMATION YOU FEEL WE NEED TO KNOW

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