Initial History Questionnaire
Date Completed
-
Month
-
Day
Year
Date
Form Completed By
First Name
Last Name
Patient's Name
First Name
Last Name
ID Number
Birth Date
-
Month
-
Day
Year
Date
Age
Household
Please list all hose living in the child's home
Are there siblings not listed above?
What is the child's living situation if not with both biological parents?
Lives with adoptive parents
Lives with foster family
Joint custody
Signle custody
If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?
Birth History
Don't know birth history
Birth Weight
Was your baby born at...
Term
Weeks
Please explain
Were there any prenatal or neonatal complications
Yes
No
Explain
Was a NICU stay required?
Yes
No
Explain
During pregnancy, did mother use tobacco
Yes
No
During pregnancy, did mother drink alcohol
Yes
No
During pregnancy, did mother use drugs or medications
Yes
No
Used prenatal vitamins
If so, please list all:
Was the delivery:
Vaginal
Cesarean
If cesarean, why?
Was initial feeding...
Formula
Breast milk
How long breastfed?
Did your baby go home with mother from the hospital?
Yes
No
Explain
General
Yes
No
Don't Know
Explain
Do you consider your child to be in good health?
Does you child have any serious illnesses or medical conditions?
Has your child had any surgery?
Has your child ever been hospitalized?
Is your child allergic to medicine or drugs?
Do you feel your family has enough to eat?
Biological Family History: Have any family members had the following?
Yes
No
Don't Know
Who
Comments
Childhood hearing loss
Nasal allergies
Asthma
Tuberculosis
Heart disease (before 55 years old)
High cholesterol / takes cholesterol medication
Anemia
Bleeding disorder
Dental decay
Cancer (before 55 years old)
Liver disease
Kidney disease
Diabetes (before 55 years old)
Bed-wetting (after 10 years old)
Obesity
Epilepsy / Convulsions
Alcohol abuse
Drug abuse
Mental illness / Depression
Developmental disability
Immune problems, HIV or AIDS
Tobacco use
Additional family history
PAST HISTORY: Does your child have, or has your child ever had
Yes
No
Don't Know
Explain
Chickenpox
Frequent ear infections
Problems with ears / hearing
Nasal allergies
Problems with eyes / vision
Asthma, bronchitis, bronchiolitis, or pneumonia
Any heart problem or heart murmur
Anemia or bleeding problem
Blood transfusion
HIV
Organ transplant
Malignancy / Bone marrow transplant
Chemotherapy
Frequent abdominal pain
Constipation requiring doctor visits
Recurrent urinary tract infections and problems
Congenital cataracts / retinoblastoma
Metabolic / Genetic disorders
Cancer
Kidney disease / Urologic malformations
Bed-wetting (after 5 years old)
Sleep problems: snoring
Chronic / recurrent skin problems (ex. acne, eczema)
Frequent headaches
Convulsions or other neurologic problems
Obesity
Diabetes
Thyroid or other endocrine problems
High blood pressure
History of serious injuries / fractures / concussions
Use of alcohol / drugs
Tobacco use
ADHD / anxiety / mood problems / depression
Developmental decay
History of family violence
Sexually transmitted infections
Pregnancy
(For girls) Problems with her periods
(For girls) Has had first period
Yes
No
Any other significant problems
Age of first period
Submit
Should be Empty: