Newborn History Form- Birth to 2 Months

Name *

First Name

Last Name

Sex

Female

Male

Other

Does your baby go to sleep easily?

Yes

No

Does your baby have a preferred sleeping position?

Yes

No

Does your baby cry when you change this sleeping position?

Yes

No

Does your baby have any feeding difficulties?

Yes

No

Is your baby breast fed?

Yes

No

Does your baby have a one-sided breast-feeding position?

Yes

No

Preferred left breast or right breast?

Left

Right

Is your baby formula fed?

Yes

No

Does your baby frequently spit-up after feeding?

Yes

No

Does your baby cry a lot?

Yes

No

Does your baby pass a lot of intestinal gas?

Yes

No

Does your baby have a preferred head position?

Yes

No

Does your baby frequently arch his/her head and neck backwards?

Yes

No

Does your baby cry or become irritable during a nappy change?

Yes

No

Has your baby ever had a fever?

Yes

No

Has your baby been in a car accident or near miss?

Yes

No

Has your baby experienced any other trauma?

Yes

No

Has your baby been vaccinated?

Yes

No

Do you have any other concerns you wish to discuss?

Yes

No