Annual Health History Update

Filled Out By:

Relationship to Child

Date:

Child's Name:

Birth Date:

Pronouns

The purpose of the questionnaire is to help us obtain information about your child and family to aid us in providing the best health care possible. Please answer all questions as they apply to your child. If a question does not apply or you prefer not to answer, leave it blank. If you do not understand a question, please please write don't understand so we can explain it further. This questionnaire will become part of your child’s health record, and as such will be strictly confidential.

Biological Sex:

Male Female

Patient Identifies as:

Sexual Orientation:

Address:

City:

State:

Zip Code:

Phone Number

Who is completing this form?

Patient

Mother

Father

Grandmother

Grandfather

Sibling

Caregiver

Foster Parent

Other

Interval Questions for Patients, Parents and Caregivers

Since your child’s last exam have there been any new concerns or problems that you would like to have checked?

Life isn’t always easy. If there's a problem, we may be able to help.

We’re asking all patients and caregivers about problems that affect many families. These problems could affect your health or that of your loved ones. You will not be judged by your answers so please be as honest as you can. You can answer any or all the questions as you see best. Your answers are private. It will only be shared with the provider.

Finances

Food

Transportation

Housing

What is your living situation today?

I have a steady place to live I have a place to live today, but am worried about losing it in the future I do not have a steady place to live

Does your current living situation have problems with (choose all that apply):

Mold

Pests (bugs, ants, mice)

Not enough heat or too much heat

Oven or stove not working

Water Leaks

Lead Paint or Pipes

In the last 12 months, how many places have you lived?

Interpersonal Safety

Stress

If you are a parent or caregiver, please complete the following two questions:

Your information will be encrypted.