New Patient Health History

Initial History Questionnaire

FORM COMPLETED BY:

DATE COMPLETED:

NAME:

ID NUMBER:

BIRTH DATE:

AGE:

GENDER:

M F

Household

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

Name:

Relationship to child:

Birth date:

Health problems:

Add more

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

Name:

Age:

Address:

Add more

What is the child's living situation if not with both biological parents?

Lives with adoptive parents Joint custody Single custody Lives with foster family

If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?

Birth History

Don't know birth history

Birth weight:

Was the baby born at term?

OR weeks?

Were there any prenatal or neonatal complications?

Yes No

Explain:

During pregnancy, did mother:

Use tobacco

Yes No

Drink alcohol

Yes No

Use drugs or medications

Yes No Used prenatal vitamins

What:

When:

General

DK = don't know

Do you consider your child to be in good health?

Yes No DK

Explain:

Does your child have any serious illnesses or medical conditions?

Yes No DK

Explain:

Has your child had any surgery?

Yes No DK

Explain:

Is your child allergic to medicine or drugs?

Yes No DK

Explain:

Do you feel your family has enough to eat?

Yes No DK

Explain:

Biological Family History

DK = don't know

Have any family members had the following?

Childhood hearing loss

Yes No DK

Who:

Comments:

Nasal allergies

Yes No DK

Who:

Comments:

Asthma

Yes No DK

Who:

Comments:

Tuberculosis

Yes No DK

Who:

Comments:

Heart disease (before 55 years old)

Yes No DK

Who:

Comments:

High cholesterol/takes cholesterol medication

Yes No DK

Who:

Comments:

Anemia

Yes No DK

Who:

Comments:

Bleeding disorder

Yes No DK

Who:

Comments:

Dental decay

Yes No DK

Who:

Comments:

Cancer (before 55 years old)

Yes No DK

Who:

Comments:

Liver disease

Yes No DK

Who:

Comments:

Kidney disease

Yes No DK

Who:

Comments:

Diabetes (before 55 years old)

Yes No DK

Who:

Comments:

Bed-wetting (after 10 years old)

Yes No DK

Who:

Comments:

Obesity

Yes No DK

Who:

Comments:

Epilepsy or convulsions

Yes No DK

Who:

Comments:

Alcohol abuse

Yes No DK

Who:

Comments:

Drug abuse

Yes No DK

Who:

Comments:

Mental illness/depression

Yes No DK

Who:

Comments:

Developmental disability

Yes No DK

Who:

Comments:

Immune problems, HIV, or AIDS

Yes No DK

Who:

Comments:

Tobacco use

Yes No DK

Who:

Comments:

Additional family history:

Past History

DK = don't know

Does your child have, or has your child ever had,

Chickenpox

Yes No DK

Who:

Comments:

Frequent ear infections

Yes No DK

Who:

Comments:

Problems with ears or hearing

Yes No DK

Who:

Comments:

Nasal allergies

Yes No DK

Who:

Comments:

Problems with eyes or vision

Yes No DK

Who:

Comments:

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No DK

Who:

Comments:

Any heart problem or heart murmur

Yes No DK

Who:

Comments:

Anemia or bleeding problem

Yes No DK

Who:

Comments:

Blood transfusion

Yes No DK

Who:

Comments:

HIV

Yes No DK

Who:

Comments:

Organ transplant

Yes No DK

Who:

Comments:

Malignancy/bone marrow transplant

Yes No DK

Who:

Comments:

Chemotherapy

Yes No DK

Who:

Comments:

Frequent abdominal pain

Yes No DK

Who:

Comments:

Constipation requiring doctor visits

Yes No DK

Who:

Comments:

Recurrent urinary tract infections and problems

Yes No DK

Who:

Comments:

Congenital cataracts/retinoblastoma

Yes No DK

Who:

Comments:

Metabolic/Genetic disorders

Yes No DK

Who:

Comments:

Cancer

Yes No DK

Who:

Comments:

Kidney disease or urologic malformations

Yes No DK

Who:

Comments:

Bed-wetting (after 5 years old)

Yes No DK

Who:

Comments:

Sleep problems; snoring

Yes No DK

Who:

Comments:

Chronic or recurrent skin problems (eg, acne, eczema)

Yes No DK

Who:

Comments:

Frequent headaches

Yes No DK

Who:

Comments:

Convulsions or other neurologic problems

Yes No DK

Who:

Comments:

Obesity

Yes No DK

Who:

Comments:

Diabetes

Yes No DK

Who:

Comments:

Thyroid or other endocrine problems

Yes No DK

Who:

Comments:

High blood pressure

Yes No DK

Who:

Comments:

History of serious injuries/fractures/concussions

Yes No DK

Who:

Comments:

Use of alcohol or drugs

Yes No DK

Who:

Comments:

Tobacco use

Yes No DK

Who:

Comments:

ADHD/anxiety/mood problems/depression

Yes No DK

Who:

Comments:

Developmental delay

Yes No DK

Who:

Comments:

Dental decay

Yes No DK

Who:

Comments:

History of family violence

Yes No DK

Who:

Comments:

Sexually transmitted infections

Yes No DK

Who:

Comments:

Pregnancy

Yes No DK

Who:

Comments:

(For girls) Problems with her periods

Yes No DK

Who:

Comments:

Has had first period

Yes No

Age of first period:

Any other significant problem:

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.
electronic. mechanical, photocopying. recording. or otherwise. without prior written permission from the publisher.

9-52/Rep0916

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