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PERSONAL INFORMATION

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* 1. What is the date of birth of the child with the Infantile Hemangioma?

Date

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* 2. What is the sex of the child?

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* 3. What is the child's race?

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* 4. When was your child diagnosed with an Infantile Hemangioma(s)?

Date

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* 5. In what country do you live?

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* 6. What state do you reside in?

INFORMATION ABOUT THE HEMANGIOMA(S)

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* 7. Type of Infantile Hemangioma (Check all that apply)

Location of Infantile Hemangioma (Check all that apply)

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* 8. Head and Neck

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* 9. Torso

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* 10. Extremities

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* 11. Multiple locations on the body?

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* 12. Internal?

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* 13. Other

INFORMATION ABOUT THE BETA BLOCKER TREATMENT

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* 14. Which beta blocker did your child take? (Check all that apply)

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* 15. Which (or both) were used?

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* 16. At what age did your child start the beta blocker?

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* 17. At what age was your child completely off of the beta blocker?

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* 18. Did you taper your child off of the beta blocker?

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* 19. If Yes, how long did you do the taper for (exact total of weeks for the taper)

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* 20. At any time during your child's treatment did you switch beta blocker type(s)?

Please indicate which changes occurred during your child's treatment (Check all that apply)

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* 21. Started with topical and then switched to one of the following oral beta blockers

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* 22. Started with oral and switched to topical

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* 23. Started with one type of oral and switched to another type of oral. Started with ?

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* 24. Switched to?

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* 25. Still on a beta blocker?

OTHER MEDICATIONS

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* 26. Please indicate any other medications that your child was taking during the time your child was taking a beta blocker:

FEEDING HABITS

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* 27. Choose all of the following that apply:

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* 28. Did your baby use a pacifier?

DENTAL ISSUES:

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* 29. Does your child have any abnormal dental issues (outside of normal developmental issues?)

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* 30. At what age did your baby's first teeth start to come in?

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* 31. At what age did you notice an abnormal issue with your baby's tooth or teeth?

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* 32. How would you describe the abnormal tooth/teeth issue(s) (Check all that apply)

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* 33. How many total teeth did your baby have when you noticed the abnormal issue?

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* 34. How many teeth were involved in an abnormal issue?

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* 35. Does your baby take fluoride tablets?

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* 36. Does your water have fluoride?

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* 37. Do you brush your baby's teeth?

SLEEP ISSUES

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* 38. Does your child have any abnormal sleep issues?

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* 39. Please indicate your child's abnormal sleep issues (Check all that apply)

ENDOCRINE ISSUES 

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* 40. Does your child have any abnormal endocrine issues?

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* 41. Please indicate your child's abnormal endocrine issues. (Check all that apply)

GROWTH ISSUES 

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* 42. Please indicate your child's growth issues. (Check one)

SKIN ISSUES

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* 43. Please indicate your child's skin issues. (Check all that apply)

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* 44. Hair thinning or hair loss?

DEVELOPMENTAL ISSUES

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* 45. Please indicate your child's developmental issues (Check one)

REFERRALS

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* 46. Did your primary care doctor refer you to a specialist for any reported side effects from the beta blocker?

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* 47. If yes, please indicate the specialist:

ADDITIONAL COMMENTS

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* 48. Please provide additional information (up to 50 words) to describe any abnormal issues with your baby during his/her time on a beta blocker.

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