Surveypoint

Q1

First Name

Patient Name

Q2

Surname

Patient Name

Q3

Parents Names

Q4

Siblings (ages)

Q5

Date of Birth

Q6

Address

Q7

Tel

Q8

Email

Q9

GP

Q10

Source of intro:

Q11

Signature

Q12

Date

Q13

Maternal Age

Q14

Number of pregnancy

Q15

Extra Scans

Q16

Special Tests

Q17

Medications

Q18

Illnesses

Q19

Accidents (Fall, Road Traffic Accident...)

Q20

Emotional Stress

Q21

Gestation (weeks)

Q22

Birth weight

Q23

Birth process

Vaginal birth

C-section birth

Q24

Spontaneous or Induced

Spontaneous

Induced

Q25

Type of Inducement

Amniotomy (Artificial Rupture of Membranes)

Prostaglandine (oral, pessary, intravenous)

Membrane Sweep

Syntocinon (Oxytocin)

Q26

1st Stage (hours)

Q27

2nd Stage (hours)

Q28

Analgesics

Gas & Air

TENS machine

Pethidine

Epidural

Spinal Block

General Anaesthesia

Q29

Instruments

Ventouse

Forceps

Other

Q30

Cord around the neck

Yes

No

Q31

Foetal distress

Yes

No

Q32

APGAR Score (../10)

Q33

Other Treatments

Reanimation

Intubation

Desobstruction

Light Therapy

Incubator

Heel Prick (Guthrie)

Dextros (diabetes)

Q34

Explain why

Q35

Head Moulding or Bruising

Q36

Feeding

Q37

Sleeping

Q38

Hospitalisations/Operations

Q39

Accidents

Q40

Baby Clinic Pre Appointment -Form Fill