Additional Information: Please upload supporting case documents...

NEC Intake Questionnaire

Contact Information:

Full Name

Date of birth

Address

Phone *

Email *

Date Today *

Injured Child’s Information:

Child Name *

Child Date of Birth *

Child Social Security Number

Child Address *

Child Phone Number

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

Child May we contact you by text message with case updates *

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

Name (write “self,” if info is same as above): *

Relationship to injured child *

Are you the legal guardian of injured child *

Address *

Phone Number *

Alternative Phone Number

Work Phone Number

E-mail *

Do you anticipate any interruptions in your phone or email service? *

May we contact you by text message with case updates *

If we are not able to reach you through the above, is there someone else we can contact to get in touch with you? (i.e., parent, spouse, close friend, etc.) *

Parents Name(s) and Contact Information:

Parent 1

Parent 1 Name

Parent 1 Date of Birth

Parent 1 Relationship to injured child

Parent 1 Is Parent No. 1 biologically related to the injured child

Parent 1 Address

Parent 1 Phone Number

Parent 1 E-mail

Parent 2

Parent 2 Name

Parent 2 Date of Birth

Parent 2 Relationship to injured child

Parent 2 Is Parent No. 2 biologically related to the injured child

Parent 2 Address

Parent 2 Phone Number

Parent 2 E-mail

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

Doctor Name

Doctor Specialty

Doctor Facility Name

Doctor Address

Doctor Phone Number

Doctor Fax Number

Other Information:

What was the original due date of the injured child? *

Was the injured child born prematurely? *

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

What was the child’s weight at birth? *

Did the injured child experience any of the following injuries?

Experience Necrotizing enterocolitis (NEC)

Experience Gastroesophageal reflux disease (GERD)

Experience Gastroesophageal reflux

Experience Hypertrophic pyloric stenosis

Experience Intussusception

Experience Meconium ileus

Experience Meconium plug syndrome

Experience Neonatal cholestasis

Experience Hernia

Experience Intestinal perforation

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? *

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

If yes, was donor milk provided before or after NEC, or both? *

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

Name:

Specialty:

Facility Name:

Address:

Phone Number:

Fax Number

What was the date that the injured child was diagnosed with NEC? *

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:

Fed Enfamil Formula

Fed Enfamil Formula Date

Fed Enfamil Milk Fortifier

Fed Enfamil Milk Fortifier Date

Fed Similac Formula

Fed Similac Formula Date

Fed Similac Milk Fortifier

Fed Similac Milk Fortifier Date

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?

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? *

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.

Neurological Damage

Have Neurological damage

Diagnosing Physician Name

Diagnosing Date

Date range treatment rendered (month/year)

Facility Name

Specialty

Address

Phone Number (if known)

Fax Number (if known)

Cerebral Palsy

Have Cerebral palsy

Diagnosing Physician Name

Diagnosing Date

Date range treatment rendered (month/year)

Facility Name

Specialty

Address

Phone Number (if known)

Fax Number (if known)

Sepsis

Have Sepsis

Diagnosing Physician Name

Diagnosing Date

Date range treatment rendered (month/year)

Facility Name

Specialty

Address

Phone Number (if known)

Fax Number (if known)

Ongoing gastrointestinal or other bowel conditions

Have Ongoing gastrointestinal or other bowel conditions

Diagnosing Physician Name

Diagnosing Date

Date range treatment rendered (month/year)

Facility Name

Specialty

Address

Phone Number (if known)

Fax Number (if known)

Intestinal perforation

Have Intestinal perforation

Diagnosing Physician Name

Diagnosing Date

Date range treatment rendered (month/year)

Facility Name

Specialty

Address

Phone Number (if known)

Fax Number (if known)

Scarring of strictures in the intestines

Have Scarring or strictures in the intestines

Diagnosing Physician Name

Diagnosing Date

Date range treatment rendered (month/year)

Facility Name

Specialty

Address

Phone Number (if known)

Fax Number (if known)

Other serious or long-lasting injuries

Have Other serious or long-lasting injuries

Injury

Diagnosing Date

Diagnosing Physician Name

Date range treatment rendered (month/year)

Facility Name

Specialty

Address

Phone Number (if known)

Fax Number (if known)

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

Has the injured child had surgeries as a result of the diagnosis or injury Date

Has the injured child had surgeries as a result of the diagnosis or injury Brief desciription

Location of each surgery

Brief description of the surgery

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 1

Hospital NEC Name

Hospital NEC Date Range

Hospital NEC Address

Hospital NEC Phone Number

Hospital NEC Fax Number

Hospital 2

Hospital 2 NEC Name

Hospital 2 NEC Date Range

Hospital 2 NEC Address

Hospital 2 NEC Phone Number

Hospital 2 NEC Fax Number

Has the injured child taken medication for their injuries?

Pharmacy 1

Pharmacy 1 Name

Pharmacy 1 Address

Pharmacy 1 Phone Number

Pharmacy 1 Fax Number

Pharmacy 2

Pharmacy 2 Name

Pharmacy 2 Address

Pharmacy 2 Phone Number

Pharmacy 2 Fax Number

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

Have Congenital heart defect

Have Antibiotic use

If yes, approximately how many days?

Have Sepsis 2

Have Blood transfusion

Have Intrauterine growth restriction

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

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