Initial History Questionnaire Form

Date

Form Completed By

Patient's Last Name

First Name

Middle Initial

Birth Date

Age

Sex

Male Female

Household

Please list all those living in the child's home

Name

Relationship to Child

Birth Date

Health Problems

Add another person living in the home

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

Yes No

Name

Age

Where do they live?

Add new row

If mother and father are not living together or if the 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 living in the home?

Birth History

Birth Weight

Was the baby born:

At Term? Early? Late?

If early, how many weeks gestation?

Did the mother have any illness or problem with her pregnancy?

Yes No

If yes, explain

During the pregnancy, did the mother Use Drugs or Medications?

Yes No

If yes, What and When?

During the pregnancy, did the mother Drink Alcohol?

Yes No

If yes, What and When?

During the pregnancy, did the mother Smoke?

Yes No

If yes, What and When?

Was the delivery

Vaginal? Cesarean?

If Cesarean, Why?

Did your baby have any problems right after birth?

Yes No

Explain

Was Initial Feeding

Breast? Bottle?

Explain

Did your baby go home with mother from the hospital?

Yes No

Explain

General

Do you consider your child to be in good 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

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:

How is your child's behavior in school?

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

How is he/she doing in academic subjects?

Is he/she in special or resource classes?

Family History

Has any family member had the following?

Deafness

Yes No

Who?

Comments

Nasal 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 Cholestererol

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

Bedwetting (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

Developmental Delay

Yes No

Who?

Comments

Immune Problems, HIV or AIDs

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

When?

Problems with ears or hearing

Yes No

When?

Nasal Allergies

Yes No

When?

Problems with eyes or vision

Yes No

When?

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No

When?

Any heart problems or heart murmur

Yes No

When?

Anemia or bleeding problem

Yes No

When?

Blood Transfusion

Yes no

When?

Frequent abdominal pain

Yes No

When?

Constipation requiring doctor visits

Yes No

When?

Bladder or kidney infection

Yes No

When?

Bedwetting (after 5 years old)

Yes No

When?

For girls: Has she started her menstrual periods?

Yes No

When?

For girls: Are there problems with her periods?

Yes No

When?

Any Chronic skin problems (acne, eczema, etc.)

Yes No

When?

Frequent Headaches

Yes No

When?

Convulsions or other neurological problems

Yes No

When?

Diabetes

Yes No

When?

Thyroid

Yes No

When?

Any other significant problems

Yes No

Explain

Use of alcohol or drugs

Yes No

When?

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

Signature of Parent/Guardian

Printed Name of Parent/Guardian

Printed Name of Patient

Date

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