Newborn Questionnaire

Primary Cellphone

Please enter a valid phone number.Format: (000) 000-0000.

Completed by (Name)Relation to child

Baby's Name

First NameLast Name

Date of Birth

Date

Baby Adopted?

Hospital, include City and State

Name of Delivery OB

Previous Primary Care Provider Name and Address

Family Profile

Mother's Name

First NameLast Name

Mother's DOB

Date

Highest School Grade

Occupation

Employer

Health

Father's Name:

First NameLast Name

Father's DOB

Date

Highest School Grade

Occupation

Employer

Health

Name

First NameLast Name

DOB

Date

Name

First NameLast Name

DOB

Date

Name

First NameLast Name

Date

Name

First NameLast Name

Date

Name

First NameLast Name

Date

Have any of your children died?

List all blood relatives of your child who have had the following problems - use abbreviation (F) Father, (M) Mother, (B) Brother, (S) Sister, (MM) Mother's Mother, (MF) Mother's Father, (FM) Father's Mother, (FF) Father's Father, (A) Aunt, (U) Uncle, (C) Cousin

Anemia/Blood Disorder

Asthma/Allergies

Intellectual Disability

Drug Problem

Alcoholism

Cancer

Sudden Infant Death

Cystic Fibrosis

Muscular Dystrophy

Tuberculosis

Arthritis/Lupus

Epilepsy/Seizures

Early Diabetes

Early Deafness

Birth Defects

AIDS

High Blood Pressure

High Cholesterol

Migraines

Heart Disease

Kidney Disease

Emotional Problems

Thyroid Disease

Inherited Disease

Other

Do you live in:

Do you know the hottest temperature of the water in your pipes?

Is there a working smoke alarm on each floor in the house?

Does your child always use a car seat/seatbelt in the car?

Are there smokers in the household?

Are there any problems with the condition of your home?

Does your house have a pool?

Are there firearms in your home?

Signature of Parent/Legal Guardian

Date

Form Disclosure

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NEWBORN QUESTIONNAIRE

Parent/Legal Guardian

Siblings

Family Medical History

Safety/Environment

Set your water heater thermostat so that the hottest temperature at the faucet is 120 degrees F to help avoid scald burns.