Health Questionnaire Form

Date

Child’s Name:

Birth Date:

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.

Filled out by:

Relationship to Child:

1. Did you have any problems during your pregnancy with this child?

Yes No

2. Were you on any medications during your pregnancy with this child?

Yes No

3. Was your child born more than two weeks early, or more than two weeks late?

Yes No

4.1. What was your child’s birth weight?

4.2. What was your child’s birth weight?

5. Did your child have any problems immediately following birth?

Yes No

6. How would you describe your child’s general health?

Excellent Good Fair Poor

7. In the past year, has your child missed more than seven days of school because of illness?

Yes No

8. Has your child ever been hospitalized? Had surgery?

Yes No

If yes, please list below:

Add hospitalization/surgery

9. Has your child ever been involved in a serious accident, or had an accidental toxic ingestion, or head injury?

Yes No

If yes, please describe:

10. At what age did your child:

Sit alone:

Dress him/herself:

Walk:

Tie his/her shoes:

Speak sentences:

Please explain

12. Does anyone in your household smoke/vape?

Yes No

13. Are there any unlocked firearms in your home?

Yes No

14. Is your water heater temperature set to 120 degrees or lower?

Yes No Don't know

15. Water Source:

Wall Town Don't know

16. Does your water have fluoride in it?

Yes No Don't know

17. Does your child ride buckled and/or in a safe car seat?

Yes No

18. Do you and your children know what to do in case of an emergency?

Yes No

19. Do you have smoke alarms in your home?

Yes No Don't know

20. Do you have carbon monoxide detectors in your home?

Yes No Don't know

We thank you for your cooperation and time in helping us provide optimal care for your child.

Your information will be encrypted.