History Questionnaire

Young Pediatrics

Form Completed by:

Date:

Patient Name:

Date of birth:

Sex:

Male Female

Household

Please list all those living in the child’s home:

Add another person living in the child home

Are there siblings not listed?

Yes No

If so, please list their names and ages and where they live.

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

Birth History

Birth Weight:

Birth Height:

Mom’s Gestation:

Did mom have any illness or problem with her pregnancy?

Yes No

If yes, explain

During pregnancy did mom smoke?

Yes No

During pregnancy did mom drink alcohol?

Yes No

During pregnancy did mom use drugs or medications?

Yes No

If yes please list what and when

Type of delivery

Vaginal Cesarean

If cesarean, why?

Did baby have any problems right after birth?

Yes No

If yes, explain

Type of Feeding:

Breast Feeding Bottle Feeding

Did baby go home with mother form hospital?

Yes No

If 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 surgery?

Yes No

Explain:

Has your child ever been hospitalized?

Yes No

Explain:

Is your child allergic to any medications or drugs?

Yes No

Explain:

Development

Are you concerned about your child’s 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:

Yes No

Explain:

How is his/her 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

Have any family members 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 age of 50 years)

Yes No

Who

Comments

High Blood Pressure (before 50 years)

Yes No

Who

Comments

High Cholesterol

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)

Yes No

Who

Comments

Bed-Wetting (after 10 years of age)

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

Mental Retardation

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

Date:

Frequent ear infections

Yes No

Explain

Problems with ears or hearing

Yes No

Explain

Nasal Allergies

Yes No

Explain

Problems with eyes or visions

Yes No

Explain

Asthma, Bronchitis, Bronchiolitis, or Pneumonia

Yes No

Explain

Any heart problem or heart murmur

Yes No

Explain

Anemia or bleeding problem

Yes No

Explain

Blood transfusion

Yes No

Explain

Frequent Abdominal pain

Yes No

Explain

Constipation requiring doctor visits

Yes No

Explain

Bladder or kidney infection

Yes No

Explain

Bed-Wetting (after 5 years of age)

Yes No

Explain

(for girls) Has she started her menstrual periods?

Yes No

When:

(for girls) Are there any problems with her periods?

Yes No

Explain

Any chronic or recurrent skin problems

Yes No

Explain

Frequent headaches

Yes No

Explain

Convulsions or other neurologic problems

Yes No

Explain

Diabetes

Yes No

Explain

Thyroid or other endocrine problems

Yes No

Explain

Any other significant problem

Yes No

Explain

Use of alcohol or drugs

Yes No

Explain

List any medications child is currently taking:

Add another medication

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