MotherToBaby North Texas * FOLLOW UP SURVEY (Individual) Please answer the following questions. Your responses will be kept in confidence. Your honest answers are valuable to us as we help future families. Name:_______________________________________ Phone Number: ________________ 1. When was your baby born? ______________________ When was he/she due? ___________ (If you had a miscarriage, please skip down to question 6.) 2. What was his/her height and weight? Height: _____ inches Weight: _____lbs _____ounces 3. Was he/she born healthy? YES ____ NO ____ If you answered "no", what problems did he/she have? ____________________________________________________________________________________________________________________________________________________________ 4. Did/does your baby have any unusual physical features: YES ____ NO ____ If you answered "yes," what features? ____________________________________________________________________________________________________________________________________________________________ If you answered "yes," are these unusual features similar to anyone else in your family, or in the baby's father's family? YES ____ NO ____ Who? __________________________________ 5. How is your new baby developing? Do you feel he/she is developing and gaining skills at the same rate as other children? YES ____ NO ____ Ahead of other babies? YES ____ NO ____ Behind other babies? YES ____ NO ____ In what areas are there delays? ____________________________________________________________________________________________________________________________________________________________ IF you did not deliver your baby, please answer questions 6 and 7, otherwise skip to question 8. 6. Did you have a spontaneous miscarriage? YES ____ NO ____ If you answered "yes", in what week did you lose your pregnancy? ____________________________________________ What do you think caused your miscarriage? ____________________________________________________________________________________________________________________________________________________________ 7. Did you elect to terminate your pregnancy? YES ____ NO ____ If you answered "yes", were any possible teratogenic exposures (medication, alcohol, drugs, chemicals) a factor in deciding to terminate? YES ____ NO ____ If "yes", what exposures caused you the most concern and distress?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. What type of possible teratogenic exposures (prescription and over-the-counter medications, alcohol, smoking, drugs, chemicals) did you have during your pregnancy? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 9. Please rate the quality of the service you were provided by us: poor 1 2 3 4 5 excellent 10. Were all of your questions and concerns answered adequately when you called us? How was our service helpful to you? What type of impact did our counseling service have on your pregnancy? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 11. Did the counseling you received from our service about your concerns/exposures make you more or less likely to call your health-care provider after speaking with us? Less Likely 1 2 3 4 5 More Likely Comments: ___________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 12. Do you remember how you heard about our service? Please check below: Doctor____ Health/Social Agency____ TV/Radio____ Planned Parenthood____ Internet____ WIC____ March of Dimes____ Book____ Previous caller____ Other____________________ 13. What do you think is the best way to let other families know about our service? ____________________________________________________________________________________________________________________________________________________________ 14. How would you improve our service? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you for taking the time to complete this survey. Please call us in the future if we can help with questions concerning breastfeeding or your next pregnancy. Please return to: Lori Wolfe UNT Dept. of Biology 1155 Union Circle, #305220 Denton, TX 76203 Phone: 1-800-733-4727 Phone: 940-565-3892 Fax: 1-940-565-2222 Email: firstname.lastname@example.org
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