Medical / Family History Questionnaire

Patient's Name

Date of Birth

Form Completed By

Today's Date

Relationship

PREGNANCY AND BIRTH HISTORY

Name of Hospital

Illnesses during pregnancy?

Yes No

Medications during pregnancy?

Yes No

Alcohol/Drug Abuse?

Yes No

Problems at birth?

Yes No

Describe

Birth Weight

Discharge Weight

Did baby receive Hepatitis B vaccine?

Yes No

Date of Hepatitis B immunization

Newborn Hearing Screen?

Yes No

PSYCHOSOCIAL HISTORY

Who lives in household?

How Many?

Rent?

Own?

Shelter?

Who cares for child?

Mothers' Date of Birth

Fathers' Date of Birth

Are parents Working?

Mother

Yes

Father

Yes

Foster Care?

Dates

Other Languages?

FAMILY HISTORY

If yes, please list who

MEDICAL HISTORY

If other, Please List

Current Medications List

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Signature

Date of Birth

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