Child History Questionnaire

Form Completed By

Date Completed

Name

ID Number

Date of Birth

Age

Sex

Male Female

Household

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

Add additional household member

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

Add additional sibling

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? If not, how many weeks?

Were there any prenatal or neonatal complications?

Yes No

If yes, please explain.

Was a NICU stay required?

Yes No

If yes, please explain.

During pregnancy, did mother use tobacco?

Yes No

During pregnancy, did mother drink alcohol?

Yes No

During pregnancy, did mother use drugs or medications?

Yes No

During pregnancy, did mother use prenatal vitamins?

Yes No

Add additional

Was the delivery vaginal or cesarean?

Vaginal Cesarean

If cesarean, why?

Was the initial feeding formula or breast milk?

Formula Breast Milk

How long breastfed?

Did your baby go home with mother from the hospital?

Yes No

If no, please explain.

General

Do you consider yourself to be in good health?

Yes No Don't Know

Explain

Does your child have any serious illnesses or medical conditions?

Yes No Don't Know

Explain

Has your child had any surgery?

Yes No Don't Know

Explain

Has your child ever been hospitalized?

Yes No Don't Know

Explain

Is your child allergic to medicine or drugs?

Yes No Don't Know

Explain

Do you feel your family has enough to eat?

Yes No Don't Know

Explain

Biological Family History

Have any family members had the following?

Childhood Hearing Loss

Yes

Don't Know

Who? Comments?

Nasal Allergies

Yes

Don't Know

Who? Comments?

Asthma

Yes

Don't Know

Who? Comments?

Tuberculosis

Yes

Don't Know

Who? Comments?

Heart Disease (before 55 years old)

Yes

Don't Know

Who? Comments?

High cholesterol/takes cholesterol medication

Yes

Don't Know

Who? Comments?

Anemia

Yes

Don't Know

Who? Comments?

Bleeding disorder

Yes

Don't Know

Who? Comments?

Dental Decay

Yes

Don't Know

Who? Comments?

Cancer (before 55 years old)

Yes

Don't Know

Who? Comments?

Liver Disease

Yes

Don't Know

Who? Comments?

Kidney Disease

Yes

Don't Know

Who? Comments?

Diabetes (before 55 years old)

Yes

Don't Know

Who? Comments?

Bed-wetting (after 10 years old)

Yes

Don't Know

Who? Comments?

Obesity

Yes

Don't Know

Who? Comments?

Epilepsy or convulsions

Yes

Don't Know

Who? Comments?

Alcohol abuse

Yes

Don't Know

Who? Comments?

Drug abuse

Yes

Don't Know

Who? Comments?

Mental illness/Depression

Yes

Don't Know

Who? Comments?

Developmental Disability

Yes

Don't Know

Who? Comments?

Immune problems, HIV, or AIDS

Yes

Don't Know

Who? Comments?

Tobacco Use

Yes

Don't Know

Who? Comments?

Additional family history

Past History

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

Chickenpox

Yes

Don't Know

When

Frequent ear infections

Yes

Don't Know

Explain

Problems with ears or hearing

Yes

Don't Know

Explain

Nasal allergies

Yes

Don't Know

Explain

Problems with eyes or vision

Yes

Don't Know

Explain

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes

Don't Know

Explain

Any heart problem or heart murmur

Yes

Don't Know

Explain

Anemia or bleeding problem

Yes

Don't Know

Explain

Blood transfusion

Yes

Don't Know

Explain

HIV

Yes

Don't Know

Explain

Organ transplant

Yes

Don't Know

Explain

Malignancy/bone marrow transplant

Yes

Don't Know

Explain

Chemotherapy

Yes

Don't Know

Explain

Frequent abdominal pain

Yes

Don't Know

Explain

Constipation requiring doctor visits

Yes

Don't Know

Explain

Recurrent urinary tract infections and problems

Yes

Don't Know

Explain

Congenital cataracts/retinoblastoma

Yes

Don't Know

Explain

Metabolic/Genetic Disorders

Yes

Don't Know

Explain

Cancer

Yes

Don't Know

Explain

Kidney disease or urologic malformations

Yes

Don't Know

Explain

Bed-wetting (after 5 years old)

Yes

Don't Know

Explain

Sleep problems; snoring

Yes

Don't Know

Explain

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

Yes

Don't Know

Explain

Frequent Headaches

Yes

Don't Know

Explain

Convulsions or other neurologic problems

Yes

Don't Know

Explain

Obesity

Yes

Don't Know

Explain

Diabetes

Yes

Don't Know

Explain

Thyroid or other endocrine problems

Yes

Don't Know

Explain

High blood pressure

Yes

Don't Know

Explain

History of serious injuries/fractures/concussions

Yes

Don't Know

Explain

Use of alcohol or drugs

Yes

Don't Know

Explain

Tobacco use

Yes

Don't Know

Explain

ADHD/anxiety/mood problems/depression

Yes

Don't Know

Explain

Developmental delay

Yes

Don't Know

Explain

Dental decay

Yes

Don't Know

Explain

History of family violence

Yes

Don't Know

Explain

Sexually transmitted infections

Yes

Don't Know

Explain

Pregnancy

Yes

Don't Know

Explain

(For girls) Problems with her periods

Yes

Don't Know

Explain

Has had first period

Yes

Age of First Period

Any other significant problems

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