New Patient Health History
Initial History Questionnaire
Household
Please list all those living in the child's home.
Are there siblings not listed? If so, please list their names, ages, and where they live.
Birth History
During pregnancy, did mother:
General
DK = don't know
Biological Family History
DK = don't know
Have any family members had the following?
Past History
DK = don't know
Does your child have, or has your child ever had,
This American Academy of Pediatrics Initial History Questionnaire is consistent with Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
HEG3l8
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations. taking into account individual circumstances, may be appropriate.
Copyright © 2010 American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced. stored in a retrieval system. or transmitted. in any form or by any means.
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9-52/Rep0916
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