Newborn Previsit Questionnaire
To provide you and your child with the best possible care, we would like to know how things are going. Please answer all the questions. Thank you.
Patient's Name
*
First Name
Last Name
Patient's date of birth
-
Month
-
Day
Year
Date
Name of person filling out form
*
First Name
Last Name
Relationship to patient
*
Mother
Father
Grandparent
Foster Parent
other relative
Vaccines for Children (VFC) Eligibility Screen:
*
My child has Medicaid insurance.
My child does not have insurance.
My child is a Native American or Alaskan Native
My child's health insurance has limited or no coverage for administration of vaccines.
My child has private insurance.
Don't know.
TELL US ABOUT YOUR BABY AND FAMILY.
What excites or delights you most about your baby?
Does your baby have special health care needs?
No
Yes
Have there been major changes lately in your family's life?
No
Yes
Have any of your baby's relatives developed new medical problems since your last visit?
No
Yes
Unsure
Does your baby live with anyone who smokes or spend time in places whre people smoke or use e-cigarettes"
No
Yes
Unsure
YOUR GROWING AND DEVELOPING BABY
Do you have specific concerns about your baby's development, learning, or behavior?
No
Yes
Check off each of the tasks that your baby is able to do.
RISK ASSESSMENT
VISION: Do you have concerns about how your baby sees?
No
Yes
Unsure
DO YOU HAVE ANY OTHER CONCERNS YOU WISH TO DISCUSS?
Yes
No
Submit
Should be Empty: