Initial History Questionnaire

Patient Name:

Date of Birth:

Sex:

Male Female

General

Do you consider your child to be in good health?

Yes No

Explain:

Does your child have any serious illness or medical condition?

Yes No

Explain:

Has your child had serious injuries or accidents?

Yes No

Explain:

Has your child had any surgery or been hospitalized?

Yes No

Explain:

Is your child on any medications (include prescription, over-the-counter, homeopathic)?

Yes No

List:

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?

Development

Are you concerned about your child’s physical development?

Yes No

Explain:

Are you concerned about your child’s mental or emotional development?

Yes No

Explain:

Are you concerned about your child’s attention span?

Yes No

Explain:

If your child is in school:

How is his/her behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing in academic subjects?

Is he/she in special or resource classes?

Are there any physical limitations with any of the following?

Vision

Patient

Yes No

Parent/Guardian

Yes No

Please explain:

Hearing

Patient

Yes No

Parent/Guardian

Yes No

Please explain:

Physical

Patient

Yes No

Parent/Guardian

Yes No

Please explain:

Learning

Patient

Yes No

Parent/Guardian

Yes No

Please explain:

Emotional

Patient

Yes No

Parent/Guardian

Yes No

Please explain:

Spiritual/Cultural

Patient

Yes No

Parent/Guardian

Yes No

Please explain:

Primary Spoken Language:

Patient

English

Parent/Guardian

English

Patient/Parent/Guardian

Other

If other, specify:

Family History

Have any family members had the following:

Deafness:

Yes No

Who:

Nasal allergies:

Yes No

Who:

Asthma:

Yes No

Who:

Tuberculosis:

Yes No

Who:

Heart disease (before 50 yrs old):

Yes No

Who:

High blood pressure (before 50 yrs old):

Yes No

Who:

High cholesterol:

Yes No

Who:

Anemia:

Yes No

Who:

Bleeding disorder: Liver Disease

Yes No

Who:

Bleeding disorder: Kidney Disease

Yes No

Who:

Diabetes (before 50 yrs old):

Yes No

Who:

Bed-wetting (after 10 yrs old):

Yes No

Who:

Epilepsy or convulsions:

Yes No

Who:

Alcohol abuse:

Yes No

Who:

Cigarette smokers:

Yes No

Who:

Drug abuse:

Yes No

Who:

Mental illness:

Yes No

Who:

Mental retardation:

Yes No

Who:

Immune problems, HIV or AIDS:

Yes No

Who:

Past History

Does your child have, or has he/she ever had:

Chickenpox:

Yes No

When:

Frequent ear infections:

Yes No

Problems with ears or hearing:

Yes No

Explain:

Allergies (nasal, allergic to medications or other):

Yes No

Explain:

Problems with eyes or vision:

Yes No

Explain:

Asthma, bronchitis, bronchiolitis, or pneumonia:

Yes No

Explain:

Any heart problem or heart murmur:

Yes No

Explain:

Anemia or bleeding problem:

Yes No

Explain:

Frequent abdominal pain:

Yes No

Constipation requiring doctor visit:

Yes No

Bladder or kidney infection:

Yes No

Explain:

Bed-wetting (after 5 yrs old):

Yes No

(Girls) Started menstrual periods?

Yes No

When:

(Girls) Problems w/ periods?

Yes No

Explain:

Chronic or recurrent skin problems (acne, eczema, etc.)?

Yes No

Explain:

Frequent headaches:

Yes No

Convulsions or other neurological problem:

Yes No

Explain:

Diabetes:

Yes No

Thyroid or other endocrine problem:

Yes No

Explain:

Use of alcohol or drugs:

Yes No

Explain:

ADHD/learning disabilities:

Yes No

Explain: