Family History Questionnaire

Patient's Name:

Date of Birth:

Sex:

Male Female

Are there any physical limitations with any of the following?

Vision

Patient:

Yes No

Parent/Guardian:

Yes No

Explain:

Hearing

Patient:

Yes No

Parent/Guardian:

Yes No

Explain:

Physical

Patient:

Yes No

Parent/Guardian:

Yes No

Explain:

Learning

Patient:

Yes No

Parent/Guardian:

Yes No

Explain:

Emotional

Patient:

Yes No

Parent/Guardian:

Yes No

Explain:

Spiritual/Cultural

Patient:

Yes No

Parent/Guardian:

Yes No

Explain:

Primary Spoken Language

Patient:

English

Parent/Guardian:

English Other

If other, explain:

Household

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

First and Last Name:

Relationship to Child:

Date of Birth:

Add new row for another household member

If there are any pets in the home, please indicate below:

Are there siblings not listed? 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?

Family History

Have any family members including parents, grandparents, & sibs had the following:

Hearing loss:

Yes No

Who:

Explain:

Nasal allergies:

Yes No

Who:

Explain:

Asthma:

Yes No

Who:

Explain:

Tuberculosis:

Yes No

Who:

Explain:

Heart disease (before 50 yrs old):

Yes No

Who:

Explain:

High blood pressure (before 50 yrs old):

Yes No

Who:

Explain:

High cholesterol:

Yes No

Who:

Explain:

Weight issues—Overweight/ Underweight:

Yes No

Who:

Explain:

Anemia:

Yes No

Who:

Explain:

Bleeding disorder:

Yes No

Who:

Explain:

Elevated Lead level:

Yes No

Who:

Explain:

Liver disease:

Yes No

Who:

Explain:

Kidney disease:

Yes No

Who:

Explain:

Diabetes (before 50 yrs old):

Yes No

Who:

Explain:

Bed-wetting (after 10 yrs old):

Yes No

Who:

Explain:

Epilepsy or seizures:

Yes No

Who:

Explain:

Alcohol abuse:

Yes No

Who:

Explain:

Cigarette smokers:

Yes No

Who:

Explain:

Drug abuse:

Yes No

Who:

Explain:

Mental illness:

Yes No

Who:

Explain:

Delayed Development:

Yes No

Who:

Explain:

Attention Deficit Disorder:

Yes No

Who:

Explain:

Learning disabilities:

Yes No

Who:

Explain:

Immune problems, HIV or AIDS:

Yes No

Who:

Explain:

Additional history:

Questionnaire completed by:

Relationship to patient:

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