Case Information

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NEC Intake Questionnaire

Today’s Date

2. Injured Child’s Information:

Name (2)

Date of Birth (2)

Social Security Number (2)

Address (2)

Phone Number (2)

E-Mail (N/A is still a baby) (2)

May We Contact You By Text Message With Case Updates (2)

3. Name of the party completing this questionnaire on behalf of the injured child:

Full Name *

Address

Phone *

Email *

Relationship to injured child

Are You The Legal Guardian Of Injured Child

May we contact you by text message with case updates

4. Parents Name(s) and Contact Information:

Parent No. 1

Name (4.1)

Date of Birth (4.1)

Relationship To Injured Child (4.1)

Is Parent No. 1 biologically related to the injured child? (4.1)

Address (4.1)

Phone Number (4.1)

E-mail (4.1)

Parent No. 2

Name (4.2)

Date of Birth (4.2)

Relationship to injured child (4.2)

Is Parent No. 2 biologically related to the injured child? (4.2)

Address (4.2)

Phone Number (4.2)

E-mail (4.2)

5. Name of the doctor or medical professional who delivered the injured child:

Name (5)

Specialty (5)

Facility Name (5)

Address (5)

Phone Number (If Known) (5)

Fax Number (if known) (5)

6. What was the original due date of the injured child?

7. Was the injured child born prematurely?

If yes, what was the injured child’s gestational age (weeks at birth)? (7)

8. What was the child’s weight at birth?

9. Was the mother’s breast milk provided to the injured child at the hospital?

If Yes, Was Mother’s Breast Milk Provided Before Or After NEC, Or Both? (9)

10. Was donor breast milk given to the injured child at the hospital?

If yes, was donor milk provided before or after NEC, or both? (10)

11. Name of doctor or medical professional who diagnosed the injured child with necrotizing enterocolitis (NEC):

Name (11)

Specialty (11)

Facility Name (11)

Address (11)

Phone Number (if known) (11)

Fax Number (if known) (11)

12. What was the date that the injured child was diagnosed with NEC?

13. Was one of the following products fed to the injured child at the hospital prior to the child’s NEC diagnosis? If so, include approx. date(s) each one was fed to the injured child:

a. Enfamil Formula (13)

A. Enfamil Formula - Date (13)

b. Enfamil Milk Fortifier (13)

B. Enfamil Milk Fortifier - Date (13)

c. Similac Formula (13)

C. Similac Formula - Date (13)

d. Similac Milk Fortifier (13)

D. Similac Milk Fortifier - Date (13)

14. To the best of your knowledge, how many days was the injured child fed formula and/or fortifier before the child was diagnosed with NEC?

15. Did the injured child pass away as a result of the NEC diagnosis or resulting injuries?

If yes, what was the injured child’s date of death? (15)

16. Was the injured child diagnosed with one of the following? If so, provide approx. date of diagnosis and the name of the medical professional who diagnosed each one.

a. Neurological damage (16)

Diagnosing Physician Name (16.a)

Diagnosing Date (16.a)

Date range treatment rendered (month/year) (16.a)

Facility Name (16.a)

Specialty (16.a)

Address (16.a)

Phone Number (if known) (16.a)

Fax Number (if known) (16.a)

b. Cerebral palsy (16)

Diagnosing Physician Name (16.b)

Diagnosing Date (16.b)

Date range treatment rendered (month/year) (16.b)

Facility Name (16.b)

Specialty (16.b)

Address (16.b)

Phone Number (if known) (16.b)

Fax Number (if known) (16.b)

c. Sepsis (severe infection in whole body) (16)

Diagnosing Physician Name (16.c)

Diagnosing Date (16.c)

Date range treatment rendered (month/year) (16.c)

Facility Name (16.c)

Specialty (16.c)

Address (16.c)

Phone Number (if known) (16.c)

Fax Number (if known) (16.c)

d. Ongoing gastrointestinal or other bowel conditions (16)

Diagnosing Physician Name (16.d)

Diagnosing Date (16.d)

Date range treatment rendered (month/year) (16.d)

Facility Name (16.d)

Specialty (16.d)

Address (16.d)

Phone Number (if known) (16.d)

Fax Number (if known) (16.d)

e. Intestinal perforation (hole in the intestines) (16)

Diagnosing Physician Name (16.e)

Diagnosing Date (16.e)

Date range treatment rendered (month/year) (16.e)

Facility Name (16.e)

Specialty (16.e)

Address (16.e)

Phone Number (if known) (16.e)

Fax Number (if known) (16.e)

f. Scarring or strictures in the intestines (16)

Diagnosing Physician Name (16.f)

Diagnosing Date (16.f)

Date range treatment rendered (month/year) (16.f)

Facility Name (16.f)

Specialty (16.f)

Address (16.f)

Phone Number (if known) (16.f)

Fax Number (if known) (16.f)

g. Other serious or long-lasting injuries (16)

Injury (16.g)

Diagnosing Date (16.g)

Diagnosing Physician Name (16.g)

Date range treatment rendered (month/year) (16.g)

Facility Name (16.g)

Specialty (16.g)

Address (16.g)

Phone Number (if known) (16.g)

Fax Number (if known) (16.g)

17. Has the injured child had surgeries as a result of the diagnosis or injury?

If yes, for each surgery please list: (1) date; (2) location of each surgery; and (3) brief description of the surgery (17)

18. Identity of all hospital(s) or medical facilities not mentioned above that have rendered treatment to the injured child for the NEC diagnosis or injuries:

Hospital/Medical Facility Name (18.a)

Date range treatment rendered (18.a)

Address (18.a)

Phone Number (if known) (18.a)

Fax Number (if known) (18.a)

Hospital/Medical Facility Name (18.b)

Date range treatment rendered (18.b)

Address (18.b)

Phone Number (if known) (18.b)

Fax Number (if known) (18.b)

19. Has the injured child taken medication for their injuries?

If yes, identify the pharmacy that fills and/or has filled prescriptions for the injured child

Pharmacy Name (19.a)

Address (19.a)

Phone Number (if known) (19.a)

Fax Number (if known) (19.a)

Pharmacy Name (19.b)

Address (19.b)

Phone Number (if known) (19.b)

Fax Number (if known) (19.b)

20. Prior to developing NEC, did the injured child experience any of the following:

a. Congenital heart defect (20)

b. Antibiotic use (20)

i. If yes, approximately how many days? (20)

c. Sepsis (20)

d. Blood transfusion (20)

e. Intrauterine growth restriction (20)

21. Anything else you would like us to know about your claim?

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