New Patient Health History

Please correct the errors described below.

Initial History Questionnaire


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

Add more

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

Add more

Birth History

During pregnancy, did mother:


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.


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.


Your information will be encrypted.