Please complete this newborn wellness check form before your scheduled appointment with Virtual Child Health. This helps us understand your baby's history, feeding, output, and any concerns you would like to discuss during the consultation.
If this is an emergency - including difficulty breathing, blue colour, poor feeding, fever in a newborn, or unusual sleepiness - seek emergency medical care immediately.
Parent or guardian details
Parent or guardian full name*
Address where the child will be during the visit*
Baby details
Baby's full name*
Sex
Please select Female Male Prefer not to say Other
Telehealth consent
I consent to a video telehealth visit for my newborn. I understand the limits of telehealth, that vaccines are not given during this visit, that the clinician may recommend urgent in-person care if needed, and that privacy will be protected as far as possible.
Newborn history
Any delivery complications?
Please select No Yes
NICU admission?
Please select No Yes
Feeding method*
Breast Bottle Both
Any latch concerns?
Please select No Yes
Any jaundice or yellowing of the skin?
Please select No Yes
Current medications or bilirubin results, if known
Parent wellbeing
I understand that the Edinburgh Postnatal Depression Scale (EPDS) may also need to be completed if requested.
Screener confirmation
Have you completed the relevant screener(s), if provided?
Please select Yes No Not yet sent to me
Measurement and visit preparation
Do you have a recent weight for your baby?
Please select Yes No
Please confirm you will try to have these ready for the visit
Baby towel or blanket Recent weight or discharge card Feed history from the last 24 hours Thermometer Phone charger A quiet well-lit room
What would you most like help with during this visit?*
Consents
I confirm that I am the parent or legal guardian of this child, or I have authority to complete this form and arrange this appointment on their behalf.
I consent to Virtual Child Health storing and processing the information submitted in order to respond to my enquiry, arrange the appointment, and document the visit in the medical record in line with the clinic privacy policy.
Go to emergency care immediately if your baby develops difficulty breathing, blue lips or face, poor feeding, fewer wet diapers than expected, marked sleepiness, high fever, seizure activity, or any other severe or rapidly worsening symptoms.
