NEWBORN QUESTIONNAIRE

NEWBORN QUESTIONNAIRE
Parent/Legal Guardian

Enter Name of person answering the following questions:
Completed by (Name)Relation to child
Baby's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Baby Adopted?

YesNo
Hospital, include City and State
Name of Delivery OB
Previous Primary Care Provider Name and Address
Family Profile

Married?Separated?Divorced?Not Married?
Mother's Name

First NameLast Name
Mother's DOB

MonthDayYear
Date
Highest School Grade
Occupation
Employer
Health
Father's Name:

First NameLast Name
Father's DOB

MonthDayYear
Date
Highest School Grade
Occupation
Employer
Health
Siblings

List the child's sisters and brothers
Name

First NameLast Name
DOB

MonthDayYear
Date
Name

First NameLast Name
DOB

MonthDayYear
Date
Name

First NameLast Name
Date

MonthDayYear
Date
Name

First NameLast Name
Date

MonthDayYear
Date
Name

First NameLast Name
Date

MonthDayYear
Date
Family Medical History
Have any of your children died?

YesNo
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
Safety/Environment
Do you live in:

A private home?Apartment?Mobile home?Other?
Do you know the hottest temperature of the water in your pipes?

YesNo
Set your water heater thermostat so that the hottest temperature at the faucet is 120 degrees F to help avoid scald burns.
Is there a working smoke alarm on each floor in the house?

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

YesNo
Are there smokers in the household?

YesNo
Are there any problems with the condition of your home?

Peeling PaintInsectsRatsMice
Does your house have a pool?

YesNo
Are there firearms in your home?

YesNo
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

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.