Initial History Questionnaire

Form completed by:

Name:

Initial Date Completed:

ID Number:

Date(s) Updated:

Birth date:

Age:

Sex

M F

GENERAL

Do you consider your child to be in good health?

Yes No Don't Know

Please explain:

Does your child have any special health care needs?

Yes No Don't Know

Please explain:

Has your child ever been hospitalized?

Yes No Don't Know

Please explain:

Is your child allergic to any medicine or drugs?

Yes No Don't Know

Please explain:

SOCIAL HISTORY

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

Add name

Please list other siblings not living in the home.

Add Sibling

Does the child live with biological parents?

Yes No

If no, what is the child's current living situation?

Single-parent custody

Joint custody

Adoptive family

Other family members

Please provide more details.

Foster care

If selected other family members, kindly indicate relationship.

How often does the child have visitation from parent(s) not living in the home.

BIRTH HISTORY

Birth weight:

Pregnancy period:

Full Term

Pre-Term

Post-Term

If pre or post-term, kindly indicate number of weeks.

Delivery:

Vaginal

Cesarean

Reason for cesarean:

Any complications during or after birth?

Yes No

Please explain:

During pregnancy, did the mother:

Take pre-natal vitamins?

Yes

Unknown

Some or use e-cigarettes?

Yes

Unknown

Drink alcohol?

Yes

Unknown

Use marijuana?

Yes

Unknown

Use illicit drugs?

Yes

Unknown

Take other medications?

Yes

Unknown

If yes, please list:

Blood type:

Mother:

Unknown

Baby:

Unknown

Mother lab results:

Hepatitis B

Pos

Neg

Unknown

HIV

Pos

Neg

Unknown

Group B Streptococus (GBS)

Pos

Neg

Unknown

After birth, did the baby get:

Vitamin K Shot

Yes

Unknown

Erythromycin eye ointment

Yes

Unknown

Hepatitis B Shot

Yes

Unknown

How was the baby fed?

Bottle formula

Bottled breast milk

Breasted

If selected breastfed, how long?

Did baby go home with biological mother from hospital after birth?

Yes No

If no, please explain:

PAST MEDICAL HISTORY

Has your child ever had any of the following problems? DK = Don't Know

Eye problems, cataracts, or retinoblastoma

DK Yes No

Details:

Vision impairment or concerns.

DK Yes No

Details:

Nasal allergies (dust, pets, or environmental)

DK Yes No

Details:

Frequent ear infections

DK Yes No

Details:

Hearing loss or concerns

DK Yes No

Details:

Multiple cavities or problems with teeth

DK Yes No

Details:

Frequent colds or sore throat

DK Yes No

Details:

Asthma, wheezing, or breathing problems

DK Yes No

Details:

Bronchitis, bronchiolitis, or pneumonia

DK Yes No

Details:

Heart murmur or other heart problems

DK Yes No

Details:

High blood pressure

DK Yes No

Details:

Frequent stomach pain

DK Yes No

Details:

Constipation needing medical treatment

DK Yes No

Details:

Food allergies or intolerance (e.g. milk, gluten)

DK Yes No

Details:

Feeding issues or underweight

DK Yes No

Details

Overweight or obesity

DK Yes No

Details:

Urinary tract infection

DK Yes No

Details:

Bed-wetting (after 5 years old)

DK Yes No

Details:

Kidney, ureter, or other problems

DK Yes No

Details:

Serious injuries or fractures

DK Yes No

Details:

Bone, joint, or muscle problems

DK Yes No

Details:

Frequent headaches or dizziness

DK Yes No

Details:

Concussion or head injury

DK Yes No

Details:

Convulsions, seizures, or neurological issues

DK Yes No

Details:

Sleep problems or snoring

DK Yes No

Details:

Skin rashes, eczema or hives

DK Yes No

Details:

Acne

DK Yes No

Details:

Thyroid or other endocrine problems

DK Yes No

Details:

Diabetes

DK Yes No

Details:

Metabolic/genetic disorders

DK Yes No

Details:

Anemia or bleeding problems

DK Yes No

Details:

Cancer or chemotherapy

DK Yes No

Details:

Bone marrow or organ transplant

DK Yes No

Details:

Blood transfusion

DK Yes No

Details:

HIV or AIDS

DK Yes No

Details:

Chickenpox or zoster (shingles)

DK Yes No

Details:

Developmental delays (speech or motor)

DK Yes No

Details:

School problems or learning difficulties

DK Yes No

Details:

ADHD or Behavioral Concerns

DK Yes No

Details

Anxiety, depression, or mood problems

DK Yes No

Details:

Tobacco, alcohol, or drug use

DK Yes No

Details:

Exposure to family violence

DK Yes No

Details:

Pregnancy

DK Yes No

Details:

Sexually transmitted infections

DK Yes No

Details:

Females: Issues with periods

DK Yes No

Details:

Age of first period:

Surgical History

Has your child ever had surgery? If yes, please provide details below.

Yes No

Add Surgical Procedure

Other surgical/procedural problems (please list):

Family History

Have any of your child's parents, grandparents, aunts, uncles, brothers, or sisters ever had any of the following conditions? DK = Don't Know

Anemia or bleeding problems

DK Yes No

Who?

Asthma

DK Yes No

Who?

Details:

Allergies

DK Yes No

Who?

Details:

Alcohol use problems

DK Yes No

Who?

Details:

Bed-wetting (after age 10 years)

DK Yes No

Who?

Details:

Cancer (before age 55 years)

DK Yes No

Who?

Details:

Childhood hearing loss

DK Yes No

Who?

Details:

Dental decay or multiple cavities

DK Yes No

Who?

Details:

Depression or anxiety

DK Yes No

Who?

Details:

Developmental disability

DK Yes No

Who?

Details:

Diabetes

DK Yes No

Who?

Details:

Heart attack (myocardial infraction)

DK Yes No

Who?

Details:

Heart disease (before age 55 years)

DK Yes No

Who?

Details:

High blood pressure

DK Yes No

Who?

Details:

High cholesterol

DK Yes No

Who?

Details:

HIV or AIDS

DK Yes No

Who?

Details:

Kidney disease

DK Yes No

Who?

Details:

Liver disease

DK Yes No

Who?

Details:

Mental Health Conditions

DK Yes No

Who?

Details:

Obesity

DK Yes No

Who?

Details:

Seizures or epilepsy

DK Yes No

Who?

Details:

Stroke

DK Yes No

Who?

Details:

Substance use problems

DK Yes No

Who?

Details:

Sudden death (before age 50 years)

DK Yes No

Who?

Details:

Thyroid or other endocrine disease

DK Yes No

Who?

Details:

Tobacco use problems

DK Yes No

Who?

Details:

Tubercolosis

DK Yes No

Who?

Details:

Vision or eye problems

DK Yes No

Who?

Details: