Initial History Questionnaire

Please correct the errors described below.


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

add another

Birth History

During pregnancy, did mother


DK = don't know

Biological Family History

DK = don't know

Have any family members had the following?

Past History

DK = don't know

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

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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