Questionnaire infants
Dear Parents,
to keep the time of waiting with your infant(s) as short as possible, I would like to ask you kindly to answer the questions listed below. Your answers in the questionnaire give me a quick overview so I can focus on the needs of your child/children and carry out the administrative tasks after treatment.
Please fill in the questionnaire before your appointment and submit it by the button
"submit data“
at the end of this questionnaire.
First Name Surname child
First Name Surname legal guardian
Address child
Address legal guardian
Date of birth
Phone number/ mobile
E-Mail address
Health Insurance/ Supplementary Insurance
Appointment
Medical history of pregnancy
The questionnaire refers to the developmental stages, i.e. diseases, accidents, psychic stress, medication.
1st Trimester, 1st -3rd month of pregnancy:
If yes, which
2nd Trimester, 4th - 6th month of pregnancy:
If yes, which
3rd Trimester, 7th - 9th month of pregnancy:
If yes, which
Medical history of birth/ delivery:
Place of delivery
Mode of delivery
Clinic
at home
Birthing center
spontaneously
Caesarean section
Term of delivery
Days
Weeks
before
after that
1
2
3
4
5
6
7
Prematurity
WOP (Weeks of Pregnancy)
Yes
No
32
33
34
35
36
Induction
Agent
Yes
No
Relaxants
Anesthetics
Tocolytics
Laber conveyor
all
Fetal presentation
Duration of Labour
Labour pains
rear occipital location
front occipital location
basin end position
transverse lie
stargazers
hoher Gradstand
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
1
2
3
4
5
6
7
Companion during Labour
If yes, who
Yes
No
Medical history after labouring (see yellow infants’ examination record)
APGAR (heart rate, breathing, tone, response, skin colour, 1-10) :
APGAR after 1 min
APGAR after 5 min
APGAR after 10 min
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Umbilibal cord
PH- level umbilical artery
Placental abruption
tension
too short
entangled
Auspulsiert
under 6,98
between 6,99-7,19
between 7,20-7,29
between 7,30-7,38
between 7,39-7,45
spontan
intervention
Weight in gram
Height in cm
Head circumference in cm
Head shape
Jaundice
Torticollis
Normal
Plagiozephalie - Parallelogramm
Brachyzephalus - levelled
Skaphozephalus - lathy
Yes
No
Yes
No
Bonding
Separation
First cry
Yes
No
Yes
No
instantly
delayed
Breastfed
How long has been breastfed
Yes
No
1 month
2 month
3 month
4 month
5 month
6 month
7 month
8 month
9 month
10 month
11 month
12 month und longer
How was the first period
for the baby
How was the first period
for the mother
Medical history till now:
Motoric development
Vaccination
Susceptibility to infection
Yes
No
Sleepdisorder
Concentration
Language
Yes
No
normal
easily distracted
only short phases of concentration
good
slight deficit
Reason:
Dear Patient,
In case your appointment needs to be cancelled, please do it if only absolutely necessary and minimum 24 hours in advance.
Appointments which weren’t cancelled in time will be charged as a private bill according to the law § 615 BGB!
Reference to corresponding fees