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

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  
Term of delivery Days Weeks
Prematurity WOP (Weeks of Pregnancy)  
Induction Agent  
Fetal presentation Duration of Labour Labour pains
Companion during Labour If yes, who  

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
Umbilibal cord PH- level umbilical artery Placental abruption
Weight in gram Height in cm Head circumference in cm
Head shape Jaundice Torticollis
Bonding Separation First cry
Breastfed How long has been breastfed  
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
Sleepdisorder Concentration Language


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