New Patient Questionnaire

Child's Name

DOB

Birth History

Weight at birth

If yes, Please Explain

What hospital was child born at?

If yes, Explain

Were there any problems right after your child was born?

Difficulty breathing

Jaundice

Heart Problem

Infection

Other

If other, Please specify

Did mom have any significant problems/illnesses during pregnancy?

Gestational Diabetes

Pre-eclampsia/High Blood Pressure

Low Fluid

Other

If Other, Please specify

Development

At what age did your child do the following?

Sit alone

Walk alone

Say first word

Has your child needed speech, physical, occupational, or other therapies

Yes No

If yes, Where?

Explain

If your child is school age, does your child have an IEP, 504, or other school difficulties?

Yes No

If yes, Please Explain

Do you have any concerns about your child's development?

Yes No

If yes, Please Explain

Past Medical History

Where did your child go for check-ups before our office?

When was your child's last check-up?

Last Dental visit?

Does your child regularly take any medications? Please include inhalers and vitamins on this list

Additional Medication

Has your child ever had a serious injury(example broken bone, concussion, etc.) or accident in their lifetime?

Yes No

Date of injury (if you do not know exact date please give age or year or injury)

Description of the injury (broken bone, concussion, car accident, etc.)

Any other doctors your child sees as a result of this injury? If so, please list name and specialty

Has your child ever had surgery?

Yes No

Please list name/reason for surgery, date (estimate if needed) and surgeon/hospital

Has your child ever had to stay overnight in the hospital?

Yes No

Please list reason, dates (estimate if needed), and which hospital

Patient Name

Date of Birth

MRN

Does your child have any allergies to medications?

Yes No

Add Medications

Does your child have any allergies to foods?

Yes No

Additional food allergies

Does your child have allergies to anything else?

Yes No

Additional Allergen

If yes, Who?

When?

Below is a list of potential medical problems or chronic diseases that can affect children. Please Select the medical problems that affect YOUR CHILD and provide details as indicated. Please provide as much information as you can recall.

Add Medical Problems

If other medical problems not listed? Please provide below.

Add Medical Problems

Family History

Below is a list of potential medical problems or chronic diseases that may affect people in your family. Please select any conditions in the family and give additional details as you are able.

Additional Conditions

If other medical problems not listed? Please provide below.

Additional Conditions

Safety Enviroment

Does anyone the child lives with or sees on a regular basis smoke (inside or outside)

Yes No

Do you live in

Private Home

Apartment/Condo

Mobile Home

Other

If other, Please specify

What year was your home built?

I don't know

Are you concerned your child may be exposed to lead?

Yes No

Is there a working smoke alarm on each floor of your home?

Yes No

Do you have any concerns about the safety of your home?

Yes No

If yes, Please explain

Please list any other questions, concerns you have or other important information you feel we need to know

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