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Baby Questionnaire
Baby Questionnaire
Child Full Name
Gender
Male
Female
Date Of Birth
Age
Chief Complaint (Medical Condition)
Name Of Parent
Gender
Male
Female
Skype Name
Email
Area Code
Phone Number
Mobile Number
Date Of Birth
Age
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to child
Is the newborn/baby comfortable in mother’s lap?
Yes - Cheerful and happy when in Mother’s arms
No - Not comfortable in mother’s arms
Other
Other
Please differentiate between the cries:
Crying due to pain there is a loud shriek, followed by a pause and then a vigorous cry.
Crying due to hunger starts with small sobs, followed by a vigorous cry.
If the baby cries for attention, then it just consists of small whining tones.
In painful cries there are always tears, whilst in hunger cries there are no tears.
Types of Crying
Soft, pitiful cry
Irritable cry
Sobs a lot
Whines and whimpers incessantly
Which breast is preferred?
Left
Right
No preference
Does the child suck slowly or vigorously?
Slowly
Vigorously
What is the frequency of the feed demanded? Some newborns need only a brief session of nursing and will be satisfied, while others will nurse for long periods and then, within a few minutes, show a strong need to suck again. Others will not really suck, but just need the nipple for mouth satisfaction.
Feels hungry immediately after nursing:
Very poor appetite:
Satisfied with a few suckles only:
Does the child go to sleep while suckling or does the child feel cheerful, weep, or become restless when suckling?
Sleep, Sleepiness, overpowering, eating after:
Sleep, Sleepiness, drinking after
Sleep, Falling asleep, eating after:
Mind, Restlessness, eating while:
Mind, cheerful after eating:
Mind, Weeping, after eating
Mind, Weeping, while eating:
Stomach, Hiccough, while eating:
Does the child perspire while suckling?
Which part of the body is mainly affected?
Does the child refuse to suck?
Does the child pass flatus, urine or stool during or after sucking?
Eating during
Eating after
It varies
The effect of giving a bath to the newborn or neonate:
Child cries, goes into convulsions or becomes stiff:
Child does not like to take a bath:
Child loves to bath and play in the water:
Child that fears during bath:
After the bath, the newborns are wrapped up in a cloth like an Egyptian mummy. Please choose appropriate:
Babies who are chilly and love warmth and coziness:
Babies who are hot will somehow slowly remove an arm, followed by another, and within a few minutes they will come out of it:
How do the eyes look? Please choose appropriate
During fright the eyes become large and starring, with dilated pupils:
In a sad child, the eyes will look small, dull, and lusterless, and the pupils will be constricted.
In a cheerful and excited child the eyes are bright and large.
What are the facial expressions while they are given a bath, being dressed (especially when they are making him wear a sweater) or lifted from the cot?
Marked fear of water (they cry and shriek when given a bath or water is sprayed on their faces)
Baby do not tolerate anything around their neck
Child cries when put into the cot, because of the fear of downward motion
Child cries when lifted from the cot
Does the child grinds his teeth, salivate, perspire, weep, shriek, laugh or jerk his limbs during sleep?
Grinds his teeth
Salivates profusely
Perspires profusely
Wimpers or weeps
Shrieks
Laughs
Jerks his limbs involuntary
Convulsions at night in sleep
If possible, mention vaccinations received:
Any adverse reactions?
Describe Childhood diseases that happened so far and if it happened twice or in a very severe form:
What medications is the child taking at the present?
How was the pregnancy?
Any worries or major events?
Did you have food cravings or strong aversions during the pregnancy?
How was the birth?
Birth weight:
At what time did the child start:
Teething
Crawling
Walking
Talking
Any skin conditions treated with cortisone cream?
When the baby is ill does he tend to cling to you or wants to be left alone?
Is the baby very affectionate when not sick?
Does the baby like music? If so, What kind?
What’s the baby attitude towards pets?
Can you think about any thing distinctive or unusual on his/her behavior like fears, desires attachments, preferences etc.?
Any surgeries? (please give details if any)
Does the baby tend to have any discharges:
Nasal
Urethral
From the Ears
Type option 4
Other
Other
Please describe colour and consistency
Does it have any particular smell?
Did the baby react bad to anesthesia or had a hard time to come out of it (e.g. headaches, vertigo, nausea, vomiting)?
Does the baby tend to react badly to medication
Yes
No
Is the baby sensitive to paint, perfumes, exhaust, fragrances, etc?
Yes
No
Fears
In what circumstances does the child feel frightened?Any fears, please specify (e.g. dark, snakes, dogs, rats, etc., heights, ghosts, robbers, claustrophobia, agoraphobia, diseases, water, death, anything that makes him/her feel uneasy):
Is there a main theme?
Temperatures
Which season bothers the baby the most?
Autumn
Winter
Spring
Summer
How do the baby feel in bright sun light?
How do the baby feels in drafts?
Any reactions before or after a storm?
How does the baby feel at seashore or high in the mountains, please specify preference?
How does the baby feel before and after meals?
Foods that you like but the baby reacts badly:
In what way?:
How many hours does the baby sleep in average (please include time to go to bed and waking up time)?
Does the baby tend to wake up in the middle of the night? And at what time?
Does the baby do anything during sleep (laugh, speak, snoring, grinding the teeth, toss about)?
How does the baby feel in the morning immediately after waking? Cranky or happy going?
In which position does the baby tend to sleep (sides, back or abdomen)?
Side
Back
Abdomen
It is quite important to observe the perspiration on the newborn child. Perspiration on:-
The nose
The upper lip
Around the eyelids and eyebrows, especially during sleep
On the scalp especially at night
Everywhere except the head
On the abdomen
On the neck
One should also check for discoloration of the cheeks.- Bluish tinged: - Pale: - Circumscribed redness of the cheeks:
Bluish tinged
Pale
Circumscribed redness of the cheeks
Other
Other
Check for wrinkles on the forehead.
Wrinkle forehead:
Wrinkle forehead in brain complaints:
Other
Other
Look for any involuntary movements.
Involuntary darting of the tongue in and out:
Nystagmus (involuntary, rapid oscillation of the eye balls.
Rhythmic oscillation of the eyeballs, either horizontal, rotary or vertical):
Skin (eruptions, itchiness):
Bowels regularity:
What Time of the Day does the baby tend to be a down and more cranky?
Is there anything else you would like to tell me?
Mother
Father
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Please try to construct a time line with major grieves/traumas that happened in your life (events that marked you or had an impact in your life in chronological order, example below)
2 month old - Dropped on the floor during nappy change
6 month old - Moving from a flat to a bigger house
1 year old - Death of grandparent that affected the mother greatly
1-2 years old - Screaming fights between parents
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