Suidi Reporting Form - Sudden Unexplained Infant Death Investigation Page 4
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8INFANT MEDICAL HISTORY (cont.)
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At any time in the infant’s life, did s/he have a history of?
Unknown
No
Yes
Discribe:
a) Allergies (food, medication, or other)
b) Abnormal growth or weight gain/loss
c) Apnea (stopped breathing)
d) Cyanosis (turned blue/gray)
e) Seizures or convulsions
f) Cardiac (heart) abnormalities
g) Metabolic disorders
h) Other
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Yes
No
Did the infant have any birth defects(s)?
_______________________________________________________________________________________________________
Describe:
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Describe the two most recent times that the infant was seen by a physician or health care provider:
(Include emergency department visits, clinic visits, hospital admissions, observational stays, and telephone calls)
First most recent visit
Second most recent visit
a) Date
/
/
/
/
Month
Day
Year
Month
Day
Year
b) Reason for visit
c) Action taken
d) Physician’s name
e) Hospital/clinic
f) Address
g) City, ZIP
h) Phone number
(
)
-
(
)
-
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Birth hospital name:
Street
City
State
ZIP
Date of discharge
/
/
Month
Day
Year
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What was the infant’s length at birth?
inches
or
centimeters
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What was the infant’s weight at birth?
pounds
ounces
or
grams
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Compared to the delivery date, was the infant born on time, early, or late?
Early - How many weeks early?
Late - How many weeks late?
On time
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Was the infant a singleton, twin, triplet, or higher gestation?
Singleton
Twi
ns
Triplet
Quadruplet or higher gestation
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Were there any complications during delivery or at birth?
(emergency c-section, child needed oxygen)
Yes
Describe the complications:
No
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Are there any alerts to pathologist? (previous infant deaths in family, newborn screen results)
Yes
Specify:
No
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