Please Register your Prem using the form below

If you have had more than one preterm please register each birth separately. If you have had multiple births please register each birth separately.

Parent information
Title:
First Name:
Surname:
Address Line 1:
Address Line 2:
Address Line 3:
Area/County:
Country:
Email Address:
Telephone Number:
Complications1
:
Complications2
:
Reason for preterm birth:
Single or Multiple births:
Number of other children:
Other preterm deliveries and years of delivery:
If you knew
:
If Your Knew2
:*
Rate a hospital
:
Rate a hospital2
:*
Access To Water etc
:
Access to water etc2
:
Infection Ctrl1
:
Infection Ctrl2
:
Support Lvl1
:
Support Lvl2
:
wasparentroom1
:
wasparentroom2
:
neonatal1
:
neonatal2
:
doyousuffer1
:
doyousuffer2
:*
attendingdoc1
:
attendingdoc2
:
sufficientlit1
:
sufficientlit2
:
infoprematurity1
:
infoprematurity2
:
infoIPB1
:
infoIPB2
:
dischNurse1
:
dischNurse2
:
For parents whose infant died while in the unit
involvInDecis1
:
involvInDecis2
:
rateComm1
:
rateComm2
:
accessToPriv1
:
accessToPriv2
:
handleArrang1
:
handleArrang2
:
accessToCounc1
:
accessToCounc2
:
followupcare1
:
followupcare2
:
anyComments1
:
anyComments2
:
Patient information while in the hospital
Year of birth:*
City of Birth:*
Hospital of Birth:
Transferred hospital (If applicable):
lenghtTHosp1
:
lenghtTHosp2
:
Birth weight:
Gestational age (weeks):
Sex:*
Health problems that your baby had in the unit:
Length of time spent as in-patient:
Was your baby readmitted to hospital at any stage:
Method of feeding baby upon discharge:
Patient follow up after discharge
Length of time attached to hospital aftercare:
Did you know your rights & entitlements:
Did your Public Health Nurse make first contact:
How soon was it after your baby’s discharge:
How many times did you see your Nurse:
What health issues did your baby present:
What other clinics/hospitals did your child attend:
Age baby formally discharged from the hospital:
How did you find the support in the community:
Could you expand on your selection:
Patient follow up after 2 years up to 18 years
What follow up therapies did your child attend:
Any other therapies:
How long did you have to wait for the appointment:
What length of time did your child attend:
Did you avail of these therapies private/public:
Assess your childs access to therapies:
Could you expand on your selection please:
What age did your child start primary school:
Did your child require a Special needs assitant:
Did your child complete State examinations:
* required        

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Ahern Byrne
                          

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