[VLN NEC] Reliable x Grombacher Intake Questionnaire

PARENT/LEGAL GUARDIAN INFORMATION

First Name *

Last Name *

Cell Phone *

Email *

Street Number & Address *

City *

State *

Zip *

Date of birth *

Last 4 of Parent's SSN *

Relationship to the child *

CHILD'S INFORMATION

Child's Full Name *

Child's Date of Birth *

Child's SSN (last 4 required)

GENERAL CASE QUESTIONS

Are you currently represented by another law firm for this matter? *

Have you spoken to another attorney regarding this matter? *

Have you signed any documents with another law firm regarding this matter? *

Was the baby diagnosed with NEC? *

How do you know the baby was diagnosed with NEC? *

What was the date of diagnosis? *

What was the gestational age of the baby at time of diagnosis in terms of weeks (Ex. 38 weeks)? *

What year was the baby born? *

Was the baby born premature prior to 36 weeks? *

How many weeks premature was the baby born? *

What was the baby's birth weight? (MUST be less than 5lbs 8oz / 2,500g) *

Please list out any of other medical conditions the child was diagnosed with. *

What kind of treatment did the child have as a result of their injury? *

BIRTH/HOSPITAL QUESTIONS

What is the name of the mother of the baby? *

What is the name of the father of the baby?

What is the name of the hospital where the baby was born? *

What state was the baby born in? *

How was the baby conceived? *

Did mom have any prior children? *

If yes, how many prior children?

How old was mom at the time of pregnancy? *

Did mom have any health issues/concerns PRIOR to pregnancy? *

Did mom have any health issues/concerns DURING pregnancy? *

Did mom have any genetic testing done DURING pregnancy? *

If yes, what were the test results?

Prior to delivery were you informed of any medical conditions the baby had or may have? *

What was the baby's birth length? *

What was the baby's Apgar scores?

Does the baby have any genetic issues? *

Could you please explain?

Was the baby admitted to the NICU? *

After birth, did the doctors or nurses have any discussions with mom about her ability to breast feed? *

What was the name of the formula or fortifier that was given to the baby? *

Was mom advised to continue providing formula or fortifier to the baby? *

What is the date of discharge from the NICU? *

Is the child still being treated for the injuries? *

Notes (Including Name and State of Treatment Hospital if child was transferred) *

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