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[VLN-NEC] Litigator Assistant - SJG Intake Questionnaire

CLIENT/PARENT INFORMATION

First Name *

Last Name *

Email *

Phone *

Client DOB *

Client Address *

CHILD’S INFORMATION

Child’s Name *

Child’s DOB *

Child’s State of Birth *

Was your child born prematurely? *

Was your child given Formula in the NICU? *

Did the Formula come in a bottle? *

Do you know if your child was given human milk with fortifier in the NICU? (Human milk fortifier comes in a paper packet and is added to human milk.) *

INITIAL AWARENESS OF POTENTIAL NEC

How did you become aware of NEC? *

Was your child diagnosed with NEC, also called necrotizing entercolitis? *

Explained what happened to your child with NEC. *

How did you learn that your child had NEC? *

How was your child treated? *

How has your child been affected by NEC? *

Did your child have to undergo surgery as a result of NEC? *

What type of surgery did your child have?

What treatment is the child receiving?

Did your child pass away as a result of NEC? *

What was the date of death?

(If not deceased) Did your child suffer injuries because of NEC? *

Does your child still receive treatment or services from the effects of NEC, and if so, what treatment or services are needed? *

BIRTH HOSPITAL

What is the name of the hospital where your child was born? *

If known, what is the address to the birth hospital? *

Was your child moved to a new hospital after he/she was born? *

Did your child receive formula or human milk fortifier at the birth hospital? *

If so, what is the name of the product provided?

NICU INFORMATION

Did the child have to stay in the NICU in the hospital where he/she was born? *

If yes, how long was the child in the NICU? *

If moved, what is the name of the hospital NICU where your child was moved to and treated?

What is the address to the hospital NICU where your child was treated? *

What was the name of the Treating Physician in the NICU?

NEC TREATMENT HOSPITAL

Was your child treated for NEC at the same hospital as birth? *

Was your child moved to a new hospital after he/she was diagnosed with NEC?

What is the Treatment Hospital Name?

What is the Treatment Hospital Address?

ADDITIONAL TREATMENT LOCATIONS

Did your child receive treatment at other healthcare facilities? *

How many other facilities?

What is the name of the 1st Additional Facility?

What is the 1st Additional Facility Address?

ADDITIONAL PARENTAL INFORMATION

Are you the Child’s Mother? *

Full Legal Name *

Have you changed your name since your child was born? *

What was your legal name at the time your child was born? *

What is the name of Child’s father?

Father’s DOB

ADDITIONAL CHILD INFORMATION

Do you know what your child’s gestational age was at birth? *

Do you know what your child’s weight was at birth? *

ADDITIONAL NEC INFORMATION

Select all types of food the child received *

Did any of your child’s caregivers discuss donor breastmilk with you? *

Do you remember the brand of Formula? If yes, please list *

Was it Similac? How do you know?

Was it Enfamil? How do you know?

Did the formula given to your child come in a bottle? *

Was your child given fortifier added to milk? *

Was the fortifier in a packet?

Do you remember if the packet used had a brand name on it?

For about how many days did your child take formula before NEC developed? *

Who decided that your child would take formula? *

Were you consulted before your child was given formula? *

Did you sign a consent form? *

To the best of your understanding, why was the formula or fortifier given to your child?

Did you know about the increased risk of NEC following the introduction of formula or fortifier? *

Did your child suffer any of the following injuries as a result of the NEC diagnosis? *

What was the date of death of your child?

Did anyone ever tell you why your baby developed NEC? *

Did your child require oxygen at birth? *

Did your baby require resuscitation (CPR) at birth? *

Are you currently represented by a law firm? If yes, please state who. *

OTHER INFORMATION

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