NEC Intake Questionnaire

Caller’s Information

Full Name (First, Middle, Last) *

Cellular Phone *

Home phone

Phone number for spouse/close relative/friend (only to be used if there is an urgent need and caller is unavailable)

Email *

Mailing Address

Relationship to Injured/Decedent (Father, Mother, Grandmother, Guardian, Adoptive Parent, Etc.)

If not mother- what is the full name of the birth mother?

Do you have legal authority to sign on the injured party's behalf?

Social Security Number

Injured/Decedent

Injured/Decedent: Full Name (First, Middle, Last)

Date of Birth (DOB)

Date of Death (if applicable)

Injured/Decedent: Social Security Number

Gender

Guardians named on birth certificate

NEC Birth and Course of Injuries

Has the child gone by any other name; have there been name changes since birth? (need to know all names to order records)

Was the child born premature?

Was there a Premature rupture of membranes (water broke) prior to birth?

Did birth mother have any prenatal infections (ex. chorioamnionitis, Urinary tract infection, etc.)?

How many weeks gestational age was the child? (need exact age, ex. 32 weeks and 2 days). Note: Some parents may only know that the child was a certain number of weeks early. This number is also acceptable.

Were there any attempts by medical staff to prevent a premature birth? If yes, what did the medical staff attempt? (Medication, cervical stitch, other?)

Did Mom have any of the following risk factors for premature birth? (Yes or No responses needed for each)

Previous premature birth(s)
Pregnancy with twins, triplets, or multiples
Less than six months between pregnancies
In vitro fertilization
Problems with uterus, cervix or placenta
Abdominal or uterine surgeries
Smoked cigarettes, marijuana or other illicit drugs
High blood pressure and/or diabetes
Prior miscarriages or abortions
Emotional and/or physical trauma/injury

Did the child have any infections (ex. Sepsis, Pneumonia, Meningitis, fungal infections, etc.)?

Did the child have Anemia?

Did the child have Hypoxia (low level of oxygen in body tissues)?

Was the child on a regimen of antibiotics?

Was the child diagnosed with NEC?

If yes, exact date?

How many days/weeks after birth was diagnosis made? (diagnosis must be made BEFORE 35 weeks gestational/age)

Was the diagnosis confirmed by x-ray?

What did the child weigh at birth?

How was the child delivered? (Natural vaginal, vaginal operative assisted (forceps, vacuum, etc.) cesarian?

Did the child sustain any injuries during birth?

Where was the child born? (Name of Hospital, city and state.)

Did the child receive? Ask if they have any pictures of the formula/fortifier

If formula or fortifier, what brand?

Were parents told whether the supplemental feeding was human-milk based fortifiers or cow-milk based fortifiers?

Were parents warned by hospital employees that feeding the child cow-milk formula could increase risks of child developing NEC?

Was the child transferred to a different medical facility for treatment?

If yes, Approximate date of transfer, name of facility, city and state.

What kind of treatment did the medical staff perform to address the NEC? (Surgery, medication, diet, etc.)

If surgery, what type of surgery and date of surgery?

If the child passed away, what was the date of death?

If the child passed away, does the death certificate state the cause of death as NEC?

If the child survived, does the child have any long-term injuries associated with NEC?

Is the child receiving any follow-up care as a result of NEC?

Name all medical facilities where follow-up care was/is provided. Name of facility, city and state.

How often are follow-ups?

Is child on any medication as a result of NEC?

Name of medication

Name of pharmacy- city and state

Referral/Dual Rep issues

How did you hear about Morelli Law?

Have you contacted any other law firms other than Morelli Law Firm?

If Yes, Name of Firm/s

Date of initial conversation

Any subsequent conversations

Signed any other retainers

Provided any other paperwork to the firm

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