Keller Postman - Flynn NEC Intake Questionnaire

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

CHILD’S INFORMATION

Child’s Name *

Child’s DOB *

Child Born Prematurely *

ADDITIONAL CHILD INFORMATION

What was your child’s gestational age at birth? *

Was the baby a boy or a girl?

Client relationship to child

What was your child’s weight at birth? *

NICU INFORMATION

Did the child have to stay in the NICU? *

Yes

No

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

Other Information

Notes

Child diagnosed with NEC? *

Yes

No

What harms did your child suffer?

My child died

My child had one or more surgeries

My child has ongoing intestinal / bowel conditions

My child has cerebral palsy / neurological cond.

Other

My child's NEC resolved without any complications

FORMULA

Child given Formula or Fortifier? *

Yes

No

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

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

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

Who decided that your child would take formula? *

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

Yes

No

Were you consulted before your child was given formula? *

Yes

No

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

Yes

No

Did you sign a consent form? *

Yes

No

NEC INJURY

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

Yes

No

Formula given to child?

Milk fortifier given to child?

Child’s Injuries *

Child died

Child had 1 or more surgeries

Child has ongoing gastrointestinal issues

Child has neurological deficits, delays or cerebral palsy

Child has other injuries

Child’s NEC resolved without any complications

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

Intestinal perforation (hole in the intestine)

Removal of a portion of the intestines

Sepsis (severe infection affecting the entire body)

Death

Intestinal or eating issues

Neurological Deficits, Delays, or Cerebral palsy

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

Yes

No

What was the date of death of your child?

State Of Death

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

Yes

No

HOSPITAL/TREATMENT INFORMATION

Did your child require oxygen at birth? *

Yes

No

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

Yes

No

Birth Hospital Name *

Birth Hospital Address *

Child’s State of Birth *

Treated at the same hospital as birth? *

Yes

No

Treatment Hospital Name *

Treatment Hospital Address *

Received treatment at other healthcare facilities? *

Yes

No

How many other facilities?

1st Additional Facility Name

1st Additional Facility Address

Treating Physician in the NICU?

CLIENT/PARENT INFORMATION

Client First Name *

Client Last Name *

Client Email *

Client Phone *

Client DOB *

Client Address *

If Child 18 or older, Their Contact Number: *

If Child 18 or older, Their Address: *

ADDITIONAL PARENTAL INFORMATION

Are you the Child’s Mother? *

Yes

No

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

Full Legal Name *

Name of Child’s father *

Father's DOB *

Coded Outcome

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