Your Name:

Your email address:

City:

State/Province:

Country:

Baby/Babies Date of Birth:

Gestational Age:

Birth Weight:

Sex of Baby/Babies:

Length of NICU stay:

Did you breastfeed / formula feed / neither / other?

Was mother given steroids before deliver?
Yes No

Was infant given medicine for PDA (hole in heart)? 
Yes No

Was your Baby &/or Babies officially diagnosed with NEC?
Yes No

If multiples, please state which baby acquired NEC
i.e. Twin A or Twin B or both:

Require Corrective Surgery? Yes No

Ilieostomy or colostomy? Yes No

Did your Baby survive? Yes No

I welcome any comments, concerns, questions, suggestions, etc. If you had multiples or more than one baby with NEC and different outcomes, please elaborate. Please be specific to gender, twin type and birth order. Thank you.

Comments Welcome

May I use your answers to compile statistics?
Yes No

Please Tell Us How You Found our Site? (ie Search Engine, word of mouth, NICU, etc.)

Thank you for your time.