[VLN-NEC] TRGP Arnold & Itkin Intake Questionnaire

Custodial Parent/Power of Attorney/Guardian over injured party (if applicable):

First Name *

Last Name *

Phone *

Email *

Relation to injured party

Address

City

State

Zip Code

Mother’s First Name

Mother’s Last Name

Mother’s name at time of pregnancy (if different)

Marital Status

Name of Spouse (if applicable)

Spouse Address

Spouse City

Spouse State

Spouse Zip Code

Spouse Cell Phone

Spouse Work Phone

Spouse Home Phone

Spouse email

Mother’s DOB

Mother’s SSN

Father’s First Name

Father’s Last Name

Father’s DOB

Father’s SSN

Other's Contact Person Name

Other's Phone

Other's Relation

Please answer the below on behalf of the injured child:

Injured Child's First Name

Injured Child's Middle Name

Injured Child's Last Name

Injured Child's Gender at Birth

Injured Child's Date of Birth

Injured Child's Date of Death (if applicable)

Injured Child's SSN

Is the injured child an incapacitated adult?

Address (if different than section 1)

Injured Child's City

Injured Child's State

Injured Child's Zip Code

Hospital(s) and Doctor(s) Information:

1) Hospital where child was born

Hospital Name

Hospital Address

Hospital City

Hospital State

Hospital Zip Code

2) NICU (Newborn Intensive Care Unit) Facility (if applicable)

NICU Facility Name

NICU Facility Address

NICU Facility City

NICU Facility State

NICU Facility Zip Code

3) Surgery Facility (if applicable)

Surgery Facility Name

Surgery Facility Address

Surgery Facility City

Surgery Facility State

Surgery Facility Zip Code

Surgeon’s Name

4) Child’s Pediatrician at time of injury

Pediatrician Name

Pediatrician Address

Pediatrician City

Pediatrician State

Pediatrician Zip Code

5) Child’s Pediatrician or Primary Care Physician currently

Pediatrician or PCP Name

Pediatrician or PCP Address

Pediatrician or PCP City

Pediatrician or PCP State

Pediatrician or PCP Zip Code

6) Medical Specialists Involved in NEC Treatment

a. Medical Specialist Name

a. Specialty

a. Medical Specialist Address

a. Medical Specialist City

a. Medical Specialist State

a. Medical Specialist Zip Code

_______________________

b. Medical Specialist Name

b. Medical Specialty

b. Medical Address

b. Medical City

b. Medical State

b. Medical Zip Code

_______________________

c. Medical Specialist Name

c. Medical Specialty

c. Medical Address

c. Medical City

c. Medical State

c. Medical Zip Code

Delivery/Injury Information

Date of birth

Due Date

Weight at Birth

Gestational Age at Birth (in weeks)

Is child deceased?

Date of Death (if applicable)

Cause of Death (if applicable)

State of Death (if applicable)

Hospitalization dates at birth (from and to)

Dates in NICU (from and to)

Date of NEC diagnosis

Surgery (If Applicable)

Surgery 1

a. Date of Surgery

a. Type of Surgery

a. Surgery Facility Name

Surgery 2

b. Date of Surgery

b. Type of Surgery

b. Surgery Facility Name

Surgery 3

c. Date of Surgery

c. Type of Surgery

c. Surgery Facility Name

Date and description of NEC treatments

Describe any ongoing medical problems or treatments related to NEC

Has the Infant been diagnosed with any of the following conditions or procedures, or received any of the following medications during the Infant’s hospitalization for his/her birth or in the NICU (if transferred), whichever is later

Healthcare Provider for the conditions, procedures or medications

Feeding Information

Did mother breastfeed while Infant was in the NICU?

Did mother pump breast milk and feed to Infant while in the NICU?

Was baby given “human donor milk”?

Was a “fortifier” added to breast milk/donor milk or formula?

Please select all formulas/fortifiers fed to injured child, and include the applicable details for each

How Given (oral, IV, nasal tube, oral tube, G-tube, J-tube) *

Duration

Facility Where Given

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