Alex Melo
baby QUESTIONNAIRE
/personal details
Name: / Date:
Phone:
Parent’s Email:
Skype Name:
Sex: / DOB (Date of Birth): / Age:
Weight: / Height:
Siblings(please state if older or younger):
Physical appearance:
CHIEF COMPLAINT (CC)
Medical diagnosis:
When did it begin?
What happen around that time?
At what time of the day or night is it better or worse?
modalities
Aggravation (what makes it worst) of Chief Complaint (food, weather, light, noise, or anything else?):
Amelioration (what makes it better) of Chief Complaint (CC):
concomitants (symptoms that appear at the same time or with the CC)
Symptoms:
Medication related to the CC:
mental / emotional
Is the newborn comfortable in the mother’s lap?
Not comfortable in mother’s arms:
Cheerful and happy when on mother’s arms:
How does he cry? The hunger cry, the painful cry, and the attention seeking cry, weeping cry, please differentiate
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.
Alex Melo
baby QUESTIONNAIRE
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:
Which breast is preferred?
Does the baby suck slowly or 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 baby go to sleep while suckling or does the baby 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 baby perspire while suckling?
Which part of the body is mainly affected?
Does the baby refuse to suck?
Does the baby pass flatus, urine or stool during or after sucking?
- Eating during:
- Eating after:
The effect of giving a bath to the newborn or neonate:
- Baby cries, goes into convulsions or becomes stiff:
- Baby does not like to take a bath:
- Baby loves to bath and play in the water:
- Baby that fears during bath:
- After the bath, the newborns are wrapped up in a cloth like an Egyptian mummy. 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?
- During fright the eyes become large and starring, with dilated pupils:
- In a sad baby, the eyes will look small, dull, and lusterless, and the pupils will be constricted.
- In a cheerful and excited baby 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:
- Baby cries when put into the cot, because of the fear of downward motion:
- Baby cries when lifted from the cot :
Does the baby grinds his teeth, salivate, perspire, weep, shriek, laugh or jerk his limbs during sleep?
- Grinds teeth:
- Salivates profusely:
- Perspires profusely:
- Whimpers or weeps:
- Shrieks:
- Laughs:
- Jerks his limbs involuntary:
- Convulsion at night in sleep:
Alex Melo
baby QUESTIONNAIRE
/It is quite important to observe the perspiration on the newborn baby.
- Perspiration on the nose:
- Perspiration on the upper lip:
- Perspiration around the eyelids and eyebrows, especially during sleep:
- Perspires on the scalp especially at night:
- Perspires everywhere, except the head:
- Perspires on the abdomen:
- Perspires on the neck:
One should also check for discoloration of the cheeks.
- Bluish tinged:
- Pale:
- Circumscribed redness of the cheeks:
Check for wrinkles on the forehead.
- Wrinkle forehead:
- Wrinkle forehead in brain complaints:
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):
fears
In what circumstances does the baby 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):
general medical history
If possible mention the Vaccinations received:
Any adverse reactions?
Describe Babyhood diseases that happened so far and if it happened twice or in a very severe form:
What medications is the baby 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 baby start teething?
Crawling: Walking: Talking:
Any skin conditions treated with cortisone cream?
When the baby is ill does he/she tend to cling to you or wants to be left alone?
What’s the baby attitude towards pets?
Is the baby very affectionate when not sick?
Does the baby like music? What kind?
Can you think about anything distinctive or unusual on his/her behavior like fears, desires attachments, preferences etc.?
Surgeries (please give details if any):
Does the baby tend to have any discharges (nasal, vaginal, or from the ears), please describe color and consistency:
sensitivity
Did the baby react bad to anesthesia, having a hard time to come out of it, or any other adverse reaction like vertigo, nausea, vomiting etc.?
Does the baby tend to react badly to medication?
Is the baby sensitive to paint, perfumes, exhaust, fragrances, etc.?
physical generals
TEMPERATURE
Which season bothers the most?
How does the baby feel in bright sun light?
How does the baby feel in drafts?
Alex Melo
baby QUESTIONNAIRE
Any reactions before or after a storm?How does the baby feel at seashore or high in the mountains, please specify preference?
FOOD
How does the baby feel before and after meals?
Foods that you like but the baby reacts badly:
And in what way?
sleep
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?
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, after waking up, cranky or happy going?
In what position does the baby usually sleeps?
What Time of the Day does the baby tend to be a down and more cranky?
Skin conditions:
Bowels regularity:
Is there anything else you would like to tell me?
family history (major conditions in their health that you can recall)
Mother:
Father:
Siblings (brother, sister):
Grandmother (mother’s side):
Alex Melo
baby QUESTIONNAIRE
Grandfather (mother’s side):Grandfather (father’s side):
Grandmother (father’s side):
Please construct a timeline of the baby with all possible traumas, diseases, important events, deaths in the family etc. (any kind of event that had an impact on the baby (bellow an example):
Timeline:
at 2 months old fell to the floor during nappy change
6 month old moved houses
1 year old death of maternal grandmother, which affected greatly the mother.
1.2 years old Screaming fight between the parents.
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