HISTORY QUESTIONNAIRE

PEDI MED CENTER

(Complete for all age patients)

Patient Name:

Date of Birth:

A. Mother's Prenatal History

Number of pregnancies

Number of living children

Name of Obstetrician

Please mark the box if the if you have health problems during your pregnancy:

Bleeding

High Blood Pressure

Surgery

Anemia

Infections

Accidents

Swelling

Other

If Other, Please specify:

Were any of the following used or taken during your pregnancy?

Medications

Cigarettes

Alcohol

Drugs

B. Birth History

Where was your child born:

Number of weeks pregnant:

Was labor induced:

Yes No

Hours of labor:

Was this a multiple birth:

Yes No

Medication:

Type of delivery:

Vaginal Forceps Cesarean

Problems or complications during labor or delivery:

Child's birth weight:

Length

Apgar Score

Type of Feeding:

Breast Formula Both

Did the child have problems in the hospital?

Breathing

Color

Feeding

Temperature

Other

Did the child go home with you?

Yes No

If no, when?

Discharge weight:

C. Family History

Age of child's mother at delivery:

Father:

Siblings:

Health problems of child's parents:

Health problems of child's siblings:

D. List below any of child's relatives (mother, father, siblings, grandparents, aunts, uncles) who have had the following illnesses:

Allergies

Yes No

Family Member

Anemia

Yes No

Family Member

Arthritis

Yes No

Family Member

Asthma,Emphysema, T.B.

Yes No

Family Member

Birth Defects

Yes No

Family Member

Blood Disease

Yes No

Family Member

Bone/Muscle Disease

Yes Option 2

Family Member

Cancer

Yes No

If yes, please specify:

Family Member

Cystic Fibrosis

Yes No

Family Member

Diabetes (Adult)

Yes Option 2

Diabetes (Juvenile)

Yes No

Family Member

Drug/Alcohol Abuse

Yes No

Family Member

Eye/ Ear Disorders

Yes No

Family Member

Heart Disease

Yes No

Family Member

High Blood Pressure

Yes No

Family Member

Infection (Frequent)

Yes No

Infection (Severe)

Yes No

Family Member

Kidney / Liver Disease

Yes No

Family Member

Learning Problems

Yes No

Family Member

Mental Illness/ Retardation

Yes No

Family Member

Metabolic / Genetic Disease

Yes No

Family Member

Nerve Disorder (Epilepsy, C.P.)

Yes No

Family Member

Rheumatic Fever

Yes No

Family Member

Sickle Sell Trait / Disease

Yes No

Family Member

TB or Exposure

Yes No

Family Member

Thyroid Disease

Yes No

Family Member

Child's Health History

Adverse reactions to medications

Adverse reactions following Immunizations

Hospitalizations

Operations

Emergency Room Visits

Does you child seem to be developing normally?

Yes No

Does your child hear well?

Yes No

Does your child see well?

Yes No

Is your child's speech understandable most of the time?

Yes No

Age when toilet trained

Does your child have any current problems?

Yes No

Do you have any concerns about your child?

Yes No

Has your child ever had any of the following? If yes, please list age:

Allergies

Yes No

Age

Anemia

Yes No

Age

Asthma

Yes No

Age

Bleeding

Yes No

Age

Cancer

Yes No

Age

Chicken Pox

Yes No

Age

Constipation, Chronic

Yes No

Age

Convulsions

Yes No

Age

Diarrhea, Chronic

Yes No

Age

Ear Problems

Yes No

Age

Eye Problems

Yes No

Age

Fractures

Yes No

Age

Kidney Infection

Yes No

Age

Leukemia

Yes No

Age

Measles

Yes No

Age

Meningitis

Yes No

Age

Pneumonia

Yes No

Age

Scarlet Fever

Yes No

Age

Sickle Cell

Yes No

Age

Tonsilitis

Yes No

Age

Whooping Cough

Yes No

Age

Other

Yes No

Age

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