Directorate of Children’s Services

Neonatal Medicine

St Michael’s Hospital

Southwell Street, Bristol, BS2 8EG

Tel: 0117 342 1725

Email: neonatologyadministration@uhbw.nhs.uk

Date:	Click here to enter a date.

PROLONGED JAUNDICE APPOINTMENT

Patient’s Name:

Date of Birth:	Click here to enter a date.

Address:

Hospital Number (if known):

NHS No:

Any family history:

Blood disorders:	No	☐ Yes	☐ thalassaemia ☐ sickle cell

Liver problems:	No ☐ Yes ☐

Any other children with jaundice:	No ☐ Yes ☐

Mum’s blood group:

Breast-fed:	No	☐ Yes ☐

When was baby first jaundiced:	Click here to enter a date.

And is it getting less:	No	☐ Yes ☐

Thriving:	No ☐ Yes ☐

Colour of stool:

Any blood results:

Any measurements:

Any further information:

Referrer’s Name (Please Print):

Based/Contact Number: