Form Soc 861 - "Safely Surrendered Baby" Medical Questionnaire
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
“SAFELY SURRENDERED BABY”
Medical Questionnaire
THANK YOU FOR CHOOSING TO GIVE THIS BABY A SAFE AND SECURE FUTURE
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. THANK YOU.
Please remember that these questions will allow us to provide the best supportive care possible to the baby. If you need
help answering any of the questions, please ask. If you are uncomfortable answering any of the questions, skip them and
answer the rest. Any information you provide will benefit the baby.
ALL INFORMATION IS CONFIDENTIAL AND WILL BE USED ONLY TO HELP CARE FOR THE BABY.
1.
What were the date, time and place of the baby’s birth?
■ ■
■ ■
.
a.m
Date:
Time:
p.m.
Place:
2.
Was the baby born early (premature)?
Late?
Unknown Due Date?
■ ■
■ ■
3.
Did the baby have any trouble starting to breathe?
Yes
No
■ ■
■ ■
4.
Has the baby been breast fed?
Yes
No
■ ■
■ ■
.
If yes, how long?
When was the baby last fed?
a.m
p.m.
■ ■
■ ■
5.
Has the baby been fed formula?
Yes
No
■ ■
■ ■
If yes, how long?
When was the baby last fed?
a.m.
p.m.
■ ■
■ ■
6.
Did the birth mother see a doctor during pregnancy?
Yes
No
If yes, when did she first see the doctor?
How many times did she see the doctor during pregnancy?
■ ■
■ ■
7.
Was the birth attended by a physician, midwife, nurse or other health care professional?
Yes
No
■ ■
■ ■
8.
Has a doctor seen the baby since birth?
Yes
No
If yes, when?
■ ■
■ ■
9.
Did the birth mother smoke cigarettes during the pregnancy?
Yes
No
If yes, how often?
■ ■
■ ■
?
10.
Did the birth mother drink alcohol during the pregnancy
Yes
No
If yes, how often?
■ ■
■ ■
11.
Did the birth mother take over the counter or prescription medication during the pregnancy?
Yes
No
If yes, what type?
How often?
■ ■
■ ■
12.
Did the birth mother take recreational or “street” drugs during the pregnancy?
Yes
No
If yes, what type?
How often?
■ ■
■ ■
13.
Has the birth mother been pregnant before?
Yes
No
If yes, how many times?
■ ■
■ ■
Were there any problems with any of those pregnancies or births?
Yes
No
Please explain
14.
Race/ethnicity of the baby’s parents: Mother
Father
■ ■
■ ■
■ ■
15.
Does the baby have any Native American ancestry?
Unknown
Yes
No
If yes, what is the name of the tribe?
From what state?
SOC 861 (10/10)
PAGE 1 OF 2
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