Kernicterus Medical Questionnaire

Patient Name
Date of Birth
Age
Today's Date
Date of Inquiry

Directions: Please answer the following questions as best you can. Some of the questions assume that parents are answering for their children, so I apologize to you if you are answering for yourself.

Contact Information

 

Child's Full Name
Gender
                   
Parent or Guardian Name
Home Address
Phone Number  
Email Address

Patient Health History

Birth Date
Birth Weight
Time of Birth
Due Date
Place of Birth
Gestational Age

Describe the Birth/Delivery History:

 

Are there any other family members who were jaundiced as infants, jaundiced as children, or are jaundiced now?

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If yes, give relationship, age, and cause of jaundice, if known:


 
Was your baby visibly jaundiced (yellow)?

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Was a bilirubin measured before discharge?

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If a bilirubin test was done, what was the highest level of total bilirubin measured, and what was the date and time?

Highest Level of Bilirubin


Date and Time
  

If you know more than one bilirubin test result, write down all the bilirubin results in a table with the date and tiem the blood was drawn, for example:

Date      Time Total Bilirubin Other Information

 

Was your child re-admitted to the hospital in the first week or two of life, and was the re-admission for jaundice?

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Was jaundice / hyperbilirubinemia treated with an exchange transfusion?

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If yes, how many?


When? (date and time, if known)


If there is auditory neuropathy, what is the age or date of diagnosis?

Age of first auditory brainstem response testing (ABR, also known as BAEP, BAER):


Results of first ABR:
       
If abnormal, was it absent?
       
How many ABRs have been done?
   

Did they:
   

Describe any behavioral, hearing, or auditory learning problems you have noticed:


Does or did your child have any developmental delays?
   

If yes, what are they?

Does or did you child have any eye movement problems, such as difficulty looking in any direction or looking up or down?

  

Does your child have any other eye movement delays?

Please describe any other issues or symptoms that you think are important to mention:

 

 

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