Initial History Questionnaire

Name

ID Number

Birth Date

Form Completed By

Date Completed

Age

Household

Please list all those living in the child's home

Add Name

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

What is the child's living situation if not 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 doe 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

Was the delivery

Vaginal Caesarean

If caesarean, why?

Were there any prenatal or neonatal complications?

Yes No

If yes, please explain.

Was a NICU stay required?

Yes No

If yes, please explain.

Was initial feeding

Formula Breast milk

How long breastfeed?

Did your baby go home with mother from the hospital?

Yes No

If no, please explain.

During the 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 illness or medical conditions?

Yes No DK

Explain

Has your child had any surgery?

Yes No DK

Explain

Has your child ever been hospitalized?

Yes No DK

Explain

Is your child allergic to medicine or drugs?

Yes No DK

Explain

Do you feel you family has enough to eat?

Yes No DK

Explain

Biological Family History

DK = "Don't Know"

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 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

Chicken pox

Yes No DK

When

Frequent ear infections

Yes No DK

Explain

Problems with ears or hearing

Yes No DK

Explain

Nasal allergies

Yes No DK

Explain

Problems with eyes or vision

Yes No DK

Explain

Asthma, bronchitis, bronchiolitis, pneumonia

Yes No DK

Explain

Any heart problem or heart murmur

Yes No DK

Explain

Anemia or bleeding problem

Yes No DK

Explain

Blood transfusion

Yes No DK

Explain

HIV

Yes No DK

Explain

Organ transplant

Yes No DK

Explain

Malignancy/bone marrow transplant

Yes No DK

Explain

Chemotherapy

Yes No DK

Explain

Frequent abdominal pain

Yes No DK

Explain

Constipation requiring doctor visits

Yes No DK

Explain

Recurrent urinary tract infections and problems

Yes No DK

Explain

Congenital cataracts/retinoblastoma

Yes No DK

Explain

Metabolic/Genetic disorders

Yes No DK

Explain

Cancer

Yes No DK

Explain

Kidney disease or urologic malformations

Yes No DK

Explain

Bed-wetting (after 5 years old)

Yes No DK

Explain

Sleep problems; snoring

Yes No DK

Explain

Chronic or recurrent skin problems (e.g. acne, eczema)

Yes No DK

Explain

Frequent headaches

Yes No DK

Explain

Convulsions or other neurologic problems

Yes No DK

Explain

Obesity

Yes No DK

Explain

Diabetes

Yes No DK

Explain

Thyroid or other endocrine problems

Yes No DK

Explain

High blood pressure

Yes No DK

Explain

History of serious injuries/fractures/concussions

Yes No DK

Explain

Use of alcohol or drugs

Yes No DK

Explain

Tobacco use

Yes No DK

Explain

ADHD/anxiety/mood problems/depression

Yes No DK

Explain

Developmental delay

Yes No DK

Explain

Dental decay

Yes No DK

Explain

History of family violence

Yes No DK

Explain

Sexually transmitted infections

Yes No DK

Explain

Pregnancy

Yes No DK

Explain

(For girls) Problems with her periods

Yes No DK

Explain

Has had first period

Yes No

Age of first period

Any other significant problem

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