Name_____________
Date______________
Newborn Questionnaire
Birth Hospital: _______________________________________ Weeks Gestation: _______
Birth: ___ Vaginal ___ C-Section
Birth Weight (lbs) _____ Birth Weight (ozs) _____ Breech Presentation: ___ Yes ___ No
Passed Hearing Screen : ___ Yes ___ No
Hep B Vaccine Administered? : ___ Yes ____ No
Ultrasound Abnormal: ____ Yes ____ No
Parental concerns this visit: _________________________________________________________
_________________________________________________________________________________
Current medications ____________________________________________
Development
Social Emotional: Eats Well: ____ Yes ____ No
Communication: Turns and calms to your voice : ____ Yes ____ No
Cognitive: Follows your face: ____ Yes ____ No
Development: Can suck, swallow, and breathe easily: ____ Yes ____ No
Family
Concerns about maternal depression: ____ Yes ____ No
Reactions of siblings to new child ___________________________________
Work plans _____________________________________________________
Child Care Plans _________________________________________________
Diet
Milk ___________________________
Type: __________________________
Amt/Time per feeding ___________________
Frequency __________________________
Vitamin A/D/C : ____ Yes ____ No
Comments: __________________________________________________
Bowel/Bladder
Stool Concerns: ____ Yes ____ No
Stool Consistency : ____ Hard ____ Soft
Urination Concerns: ____ Yes ____ No
Comments : __________________________________________________
Sleep
Back Sleeping : ____ Yes ____ No
Duration: ____ <2 hrs ____ 2-4 hrs ____ >4 hrs
Location ____ co-sleep ____ crib ____ co-sleep & crib
Tobacco Exposure: ____ Yes ____ No
Behavior concerns : ____ Yes ____ No
Childcare ________________________________________
