New Patient Questionnaire

CHILD'S NAME:

DOB:

FORM COMPLETED BY:

Household

What is the child's living situation? Lives with:

Biological Parents Adoptive Parents Foster Family Joint Custody Single Custody Other

If you selected Single Custody, who do they live with:

If you selected Other, please specify:

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

Add another person

Birth History

I do not know the birth history

Birth weight:

Was the child born at term?

Yes No

If preterm, how many weeks?

Was the baby conceived by IVF or other forms of assisted fertility?

Yes No

If yes, did you use a donor egg or donor sperm?

Were there any prenatal or neonatal complications?

Yes No

Explain:

During pregnancy, did mother:

Use tobacco

Drink alcohol

Use drugs

Take medication

Explain:

Any other information you feel the pediatrician should know?

General Medical History

I do not know (DK)

Do you consider your child to be in good health?

Yes No DK

Explain:

Has your child had any surgery?

Yes No DK

If applies:

Add another surgery

Has your child ever been hospitalized?

Yes No DK

Add more

Is your child allergic to any medication or food?

Yes No DK

Explain:

Current Medications:

Any significant past medications the doctor should know about?

Past History

I do not know (DK) the child's past history

Does your child have, or has your child ever had

Chickenpox:

Y N DK

When:

Frequent ear infections/ problems with ears or hearing:

Y N DK

Explain:

Asthma, bronchitis, bronchiolitis, or pneumonia:

Y N DK

Explain:

Any heart problems / heart murmur / high blood pressure:

Y N DK

Explain:

Anemia / bleeding problems / blood transfusions:

Y N DK

Explain:

Frequent abdominal pain / intestinal problems/constipation:

Y N DK

Explain:

Recurrent urinary tract infections:

Y N DK

Explain:

Kidney disease or urological malformations:

Y N DK

Explain:

Bed-Wetting: (after 6 years old)

Y N DK

Explain:

Eye Problems/ Cataracts/ Retinoblastoma:

Y N DK

Explain:

Metabolic/ Genetic Disorder:

Y N DK

Explain:

Sleeping problems / snoring:

Y N DK

Explain:

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

Y N DK

Explain:

Immune Problem/TB/HIV:

Y N DK

Explain:

Autoimmune Disease:

Y N DK

Explain:

Cancer or Tumor:

Y N DK

Explain:

Frequent Headaches/Migraines:

Y N DK

Explain:

Seizure Disorder:

Y N DK

Explain:

Obesity/Eating Disorder:

Y N DK

Explain:

Diabetes:

Y N DK

Explain:

Thyroid or other endocrine problems:

Y N DK

Explain:

History of serious injuries/ fractures/concussions:

Y N DK

Explain:

ADHD:

Y N DK

Explain:

Learning Disabilities / Cognitive Delay:

Y N DK

Explain:

Developmental Delay:

Y N DK

Explain:

Autism:

Y N DK

Explain:

Anxiety/ Mood problems/ Depression/ Psychiatric Illness:

Y N DK

Explain:

History of family violence:

Y N DK

Explain:

Any other significant problems:

Your information will be encrypted.