Form Mc 356 - Medical Questionnaire
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2State of California—Health and Human Services Agency
Department of Health Care Services
ID number: ____________________
“SAFE ARMS FOR NEWBORNS”
Medical Questionnaire
NOTICE: THE BABY YOU HAVE BROUGHT IN TODAY MAY HAVE SERIOUS MEDICAL NEEDS IN THE
FUTURE THAT WE DON’T KNOW ABOUT TODAY. SOME ILLNESSES, INCLUDING CANCER, ARE
BEST TREATED WHEN WE KNOW ABOUT FAMILY MEDICAL HISTORIES. IN ADDITION, SOMETIMES
RELATIVES ARE NEEDED FOR LIFE-SAVING TREATMENTS. TO MAKE SURE THIS BABY WILL HAVE
A HEALTHY FUTURE, YOUR ASSISTANCE IN COMPLETING THIS QUESTIONNAIRE FULLY IS
ESSENTIAL.
ALL INFORMATION WILL BE CONFIDENTIAL AND WILL BE USED ONLY TO HELP CARE FOR THE BABY.
THANK YOU
1. Has the baby been named?
Yes
No
If yes, what is the baby’s name? _______________________________________________
2. What was the date, time, and place of the baby’s birth?
Date: _______________________
Time: ___________________
Place:_______________________________
3. How much did the baby weigh at birth? ________________________
4. Has the baby been breast-fed?
Yes
No
If yes, how long? ___________________________
When was the baby last fed? _____________________________
5. Has the baby been fed baby formula?
Yes
No
If yes, what is the name of the formula? ________________________________________________________________
6. How long was the labor with this baby?_________________________________________________________________
7. Did the birth mother see a doctor during this pregnancy?
Yes
No
If yes, when did she first see the doctor? _______________________________________________________________
How many times during the pregnancy was the birth mother seen by a doctor? _________________________________
8. Did a pediatrician examine the baby at birth?
Yes
No
9. Has a doctor seen the baby since its birth?
Yes
No
If yes, when? _____________________________________________________________________________________
10. Did the birth mother smoke cigarettes during this pregnancy?
Yes
No
If yes, how often? __________________________________________________________________________________
11.
Did the birth mother drink alcohol during this pregnancy?
Yes
No
If yes, how often? __________________________________________________________________________________
12. Did the birth mother take any over-the-counter or prescription medication during this pregnancy?
Yes
No
If yes, what medications? __________________________________________
How often? ______________________
13. Did the birth mother use any illegal or “street” drugs during this pregnancy?
Yes
No
If yes, what? ______________________________
How often?__________________________________________
14. Has the birth mother been pregnant before?
Yes
No
If yes, how many times?___________________________________________
Were there complications with any of the pregnancies or births?
Yes
No
Please explain: ____________________________________________________________________________________
________________________________________________________________________________________________
15. What race/ethnicity are the baby’s parents?
Mother: ____________________
Father: ____________________
Does the baby have Native American ancestry?
Yes
No
If yes, what is the name of the tribe? ___________________________________________________________________
MC 356 (05/07)
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