Initial History Questionnaire

Form Completed By:

Date Completed:

Name:

ID Number:

Birth Date:

Age:

Sex:

M F

Household

Please list all those living in the child's home.

add another

Are there siblings not listed? If so, please list their names, ages, and where they live.

What is the child's living situation if not with both biological parents?

Lives with adoptive parents

Lives with foster family

Joint custody

Single 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 the baby born at term?

OR weeks

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

Drink alcohol:

Yes No

Use drugs or medications:

Yes No Used prenatal vitamins

What:

When:

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

DK = don't know

Do you consider your child to be in good health?

Yes No DK

Explain:

Does your child have any serious illnesses or medical conditions?

Yes No DK

Explain:

Has your child had any surgery?

Yes No DK

Explain:

Has your child ever been hospitalized?

Yes No DK

Explain:

Is your child allergic to medicine or drugs?

Yes No DK

Explain:

Do you feel your family has enough to eat?

Yes No DK

Explain:

Biological Family History

DK = don't know

Have any family members had the following?

Childhood hearing loss:

Yes No DK

Who:

Comments:

Nasal allergies:

Yes No DK

Who:

Comments:

Asthma:

Yes No DK

Who:

Comments:

Tuberculosis:

Yes No DK

Who:

Comments:

Heart disease (before 55 years old):

Yes No DK

Who:

Comments:

High cholesterol/takes cholesterol medication:

Yes No DK

Who:

Comments:

Anemia:

Yes No DK

Who:

Comments:

Bleeding disorder:

Yes No DK

Who:

Comments:

Dental decay:

Yes No DK

Who:

Comments:

Cancer (before 55 years old):

Yes No DK

Who:

Comments:

Liver disease:

Yes No DK

Who:

Comments:

Kidney disease:

Yes No DK

Who:

Comments:

Diabetes (before 55 years old):

Yes No DK

Who:

Comments:

Bed-wetting (after 10 years old):

Yes No DK

Who:

Comments:

Obesity:

Yes No DK

Who:

Comments:

Epilepsy or convulsions:

Yes No DK

Who:

Comments:

Alcohol abuse:

Yes No DK

Who:

Comments:

Drug abuse:

Yes No DK

Who:

Comments:

Mental illness/depression:

Yes No DK

Who:

Comments:

Developmental disability:

Yes No DK

Who:

Comments:

Immune problems, HIV. or AIDS:

Yes No DK

Who:

Comments:

Tobacco use:

Yes No DK

Who:

Comments:

Additional family history:

Past History

DK = don't know

Does your child have, or has your child ever had,

Chickenpox:

Yes No DK

When:

Frequent ear infections:

Yes No DK

Explain:

Problems with ears or hearing:

Yes No DK

Explain:

Nasal allergies:

Yes No DK

Explain:

Problems with eyes or vision:

Yes No DK

Explain:

Asthma, bronchitis, bronchiolitis, or pneumonia:

Yes No DK

Explain:

Any heart problem or heart murmur:

Yes No DK

Explain:

Anemia or bleeding problem:

Yes No DK

Explain:

Blood transfusion:

Yes No DK

Explain:

HIV:

Yes No DK

Explain:

Organ transplant:

Yes No DK

Explain:

Malignancy/bone marrow transplant:

Yes No DK

Explain:

Chemotherapy:

Yes No DK

Explain:

Frequent abdominal pain:

Yes No DK

Explain:

Constipation requiring doctor visits:

Yes No DK

Explain:

Recurrent urinary tract infections and problems:

Yes No DK

Explain:

Congenital cataracts/retinoblastoma:

Yes No DK

Explain:

Metabolic/Genetic disorders:

Yes No DK

Explain:

Cancer:

Yes No DK

Explain:

Kidney disease or urologic malformations:

Yes No DK

Explain:

Bed-wetting (after 5 years old):

Yes No DK

Explain:

Sleep problems; snoring:

Yes No DK

Explain:

Chronic or recurrent skin problems (eg. acne, eczema):

Yes No DK

Explain:

Frequent headaches:

Yes No DK

Explain:

Convulsions or other neurologic problems:

Yes No DK

Explain:

Obesity:

Yes No DK

Explain:

Diabetes:

Yes No DK

Explain:

Thyroid or other endocrine problems:

Yes No DK

Explain:

High blood pressure:

Yes No DK

Explain:

History of serious injuries/fractures/concussions:

Yes No DK

Explain:

Use of alcohol or drugs:

Yes No DK

Explain:

Tobacco use:

Yes No DK

Explain:

ADHD/anxiety/mood problems/depression:

Yes No DK

Explain:

Developmental delay:

Yes No DK

Explain:

Dental decay:

Yes No DK

Explain:

History of family violence:

Yes No DK

Explain:

Sexually transmitted infections:

Yes No DK

Explain:

Pregnancy:

Yes No DK

Explain:

(For girls) Problems with her periods:

Yes No DK

Explain:

Has had first period

Yes No

Age of first period:

Any other significant problem:

This American Academy of Pediatrics Initial History Questionnaire
is consistent with Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.

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