Cerebral Palsy Information Questionnaire

Did your baby require a breathing tube?

Name*

First Last

Email*

Phone

Please provide your phone number in case we have questions about the information you have submitted.

Does your child have cerebral palsy or brain damage?

How many weeks pregnant were you at time of delivery?

Baby's birth year?*

Baby's birth province?*

How did Mom deliver?

Was the baby's heart rate dropping prior to birth?

Was the baby breathing after birth?

Apgar scores, if known.

Did your baby require a breathing tube?

Did your baby have seizures, shakes or tremors within 48 hours after delivery?

Was your baby transferred to the Neonatal Intensive Care Unit?

Did your baby have an MRI, Ultrasound, or CT of the brain?

What were the results?

How long did your baby remain in the hospital?

Do you have any additional message or information you would like to provide?