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 - Edinburgh Postnatal Depression Scale (EPDS)
Please select the answer that comes closest to how you have felt in the past 7 days.
1. I have been able to laugh and see the funny side of things
Please select As much as I always could Not quite so much now Definitely not so much now Not at all
2. I have looked forward with enjoyment to things
Please select As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all
3. I have blamed myself unnecessarily when things went wrong
Please select Yes, most of the time Yes, some of the time Not very often No, never
4. I have been anxious or worried for no good reason
Please select No, not at all Hardly ever Yes, sometimes Yes, very often
5. I have felt scared or panicky for no very good reason
Please select Yes, quite a lot Yes, sometimes No, not much No, not at all
6. Things have been getting on top of me
Please select Yes, most of the time I haven't been able to cope at all Yes, sometimes I haven't been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever
7. I have been so unhappy that I have had difficulty sleeping
Please select Yes, most of the time Yes, sometimes Not very often No, not at all
8. I have felt sad or miserable
Please select Yes, most of the time Yes, quite often Not very often No, not at all
9. I have been so unhappy that I have been crying
Please select Yes, most of the time Yes, quite often Only occasionally No, never
10. The thought of harming myself has occurred to me
Please select Yes, quite often Sometimes Hardly ever Never
If you have had thoughts of harming yourself or your baby, or you feel you are in immediate danger, seek urgent emergency help immediately.
EPDS copyright notice: Cox, J.L., Holden, J.M., and Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.
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.
