Initial History Questionnaire

Child's Name

Birth Date

Home Phone

Parent/Guardian (1) Name

Parent/Guardian (2) Name

Address

Work Phone Parent/Guardian(1)

Cell Phone Parent/Guardian(1)

Employer Parent/Guardian(1)

Work Phone Parent/Guardian(2)

Cell Phone Parent/Guardian(2)

Employer Parent/Guardian(2)

Referred By

Email address

HOUSEHOLD

Please list all those living in the child’s home

Add Name

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

Have any of your children died?

If Parents/Guardians are not living together or if child does not live with parents, what is the child’s custody status?

If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home?

BIRTH HISTORY

Apgar Scores

Birth weight

If cesarean, why?

If early, how many weeks’ gestation?

If yes, Please Explain

Did your baby go home with mother from the hospital?

Yes No

Explain

During pregnancy, did mother Smoke?

Yes No

Drink alcohol?

Yes No

Use drugs or medications?

Yes No

What?

When

GENERAL

Do you have specific concerns about your child’s health?

Yes No

Explain

Does your child have any serious illness or medical condition?

Yes No

Explain

Has your child had serious injuries or accidents?

Yes No

Explain

Has your child had any surgery?

Yes No

Explain

Has your child ever been hospitalized?

Yes No

Explain

Is your child allergic to any medicines or drugs?

Yes No

Explain

In times of stress, do you have support available?

Yes No

Explain

DEVELOPMENT

Are you concerned about your child’s physical development?

Yes No

Explain

Are you concerned about your child’s mental or emotional development?

Yes No

Explain

Are you concerned about your child’s attention span?

Yes No

Explain

If your child is in school

Are you concerned about his/her behavior in school?

Yes No

Explain

Has he/she failed or repeated a grade in school?

Yes No

Explain

Are you concerned about how he/she is doing in academic subjects?

Yes No

Explain

Is he/she in special or resource classes?

Yes No

Explain

Does he/she have problems getting along well with other children?

Yes No

Explain

FAMILY HISTORY

Have any family members had the following?: (including parents, grandparents, aunts, uncles and cousins)

Deafness

Yes No

Who?

Comments

Nasal allergies or food allergies

Yes No

Who?

Comments

Asthma

Yes No

Who?

Comments

Tuberculosis

Yes No

Who?

Comments

Heart disease (before 50 years old)

Yes No

Who?

Comments

High blood pressure (before 50 years old)

Yes No

Who?

Comments

High cholesterol

Yes No

Who?

Comments

Anemia

Yes No

Who?

Comments

Bleeding disorder

Yes No

Who?

Comments

Liver disease

Yes No

Who?

Comments

Kidney disease

Yes No

Who?

Comments

Diabetes (before 50 years old)

Yes No

Who?

Comments

Bed-wetting (after 10 years old)

Yes No

Who?

Comments

Epilepsy or convulsions

Yes No

Who?

Comments

Alcohol abuse

Yes No

Who?

Comments

Drug abuse

Yes No

Who?

Comments

Mental illness

Yes No

Who?

Comments

Intellectual/Developmental Disability

Yes No

Who?

Comments

Immune problems, HIV or AIDS

Yes No

Who?

Comments

Cancer

Yes No

Who?

Comments

Additional family history

PAST HISTORY

Does your child have, or has he/she ever had?

Chickenpox

Yes No

When?

Frequent ear infections

Yes No

Explain?

Problems with ears or hearing

Yes No

Explain?

Nasal allergies or food allergies

Yes No

Explain?

Problems with eyes or vision

Yes No

Explain?

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No

Explain?

Any heart problem or heart murmur

Yes No

Explain?

Anemia or bleeding problem

Yes No

Explain?

Blood transfusion

Yes No

Explain?

Frequent abdominal pain

Yes No

Explain?

Constipation requiring doctor visits

Yes No

Explain?

Bladder or kidney infection

Yes No

Explain?

Bed-wetting (after 6 years old)

Yes No

Explain?

(For girls) Has she started her menstrual periods?

Yes No

When?

(For girls) Are there problems with her periods?

Yes No

Explain?

Any chronic or recurrent skin problem (acne, eczema, etc.)

Yes No

Explain?

Frequent headaches

Yes No

Explain?

Convulsions or other neurological problem

Yes No

Explain?

Diabetes

Yes No

Explain?

Thyroid or other endocrine problem

Yes No

Explain?

Any other significant problem

Yes No

Explain?

Use of alcohol or drugs

Yes No

Explain?

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.