Case Information

[VLN-NEC] Schrader Law - Levin Papantonio NEC Intake Questionnaire

Baby Formula Intake Questionnaire

Contact Details

Injured name *

DOB-Injured Part *

Single, Widow, Divorced, Married (if married, spouse name)

Caller Name (if different) *

Caller’s relationship to injured person *

Why are you calling rather than the injured person?

Mailing Address (street/PO Box, city, state, zip) *

Physical Address, if different: (street, city, state) *

Cell Phone *

May we text you? If yes, who is your provider *

Home phone

Work phone

Email Address *

Preferred method of contact *

What's the best time to call you? *

If Injured Person Is Deceased

Date of Death

Cause(s) of Death

Residency at time of Death (city & state)

Has an Estate been opened

Appointed Personal Representative

Injury 1

Has your child been dx with necrotizing enterocolitis (NEC)? *

If yes, when was diagnosis made (month/year)? *

Name of diagnosing physician *

Location (city/state) *

What treatment has your child received? *

Injury 2

Has your child been dx with cerebral palsy, bowel resection, gastrointestinal distress, or other serious injury? *

Has your child been dx with cerebral palsy, bowel resection, gastrointestinal distress, or other serious injury? If yes, what *

When was diagnosis made (month/year)? *

Name of diagnosing physician *

Has your child had surgery due to this condition? *

Location (city/state) (2) *

If yes, date of surgery *

Child’s Name *

Was your child born prematurely? *

Birth weight *

If so, what gestational week was your child born (how far along in the pregnancy) *

Is child deceased? *

Cause of death

Was your baby given Similac or Enfamil while in the hospital? *

Name of the hospital *

Location of hospital (city/state) *

When discharged home, did you feed your baby one of the following formulas? (identify all that apply)

Details *

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