Pediatric Associates of Denham Springs

INITIAL HISTORY QUESTIONNAIRE

Form Completed by

Date Completed

Name

ID Number

Birth Date

Age

Gender

M F

Name

Relationship to child

Birthdate

Health Problems

Add New

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

What is the child's living situation if not with 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 ofter does 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?

Weeks

Were there any prenatal or neonatal complications?

Yes No

Explain

Was a NICU required?

Yes No

Explain

During Pregnancy, did mother

Use tobacco

Yes No

Drink alcohol

Yes No

Use drugs or medications

Yes No Used prenatal vitamins

When

What

Was the delivery

Vaginal Cesarean

If cesarean, why?

What is the initial feeding

Formula Breast Milk

How long breastfed?

Did your baby go home with mother from the hospital?

Yes No

Explain

GENERAL

Do you consider your child to be in good health?

Yes No Don't know

Explain

Does you child have any serious illness or medical conditions?

Yes No Don't know

Explain

Has your child had any surgery?

Yes No Don't know

Explain

Has your child ever been hospitalized?

Yes No Don't know

Explain

Is your child allergic to medicine or drugs?

Yes No Don't know

Explain

Do you feel your family has enough to eat?

Yes No Don't know

Explain

BIOLOGICAL FAMILY HISTORY

Has any family members had the following?

Child Hearing Loss

Yes No Don't know

Comments

Who

Nasal Allergies

Yes No Don't know

Comments

Who

Asthma

Yes No Don't know

Comments

Who

Tubercolosis

Yes No Don't know

Comments

Who

Heart Disease (before 55 years old)

Yes No Don't know

Comments

Who

High cholesterol / takes cholesterol medication

Yes No Don't know

Comments

Who

Anemia

Yes No Don't know

Comments

Who

Bleeding Disorder

Yes No Don't know

Comments

Who

Dental Decay

Yes No Don't know

Comments

Who

Cancer (before 55 years old)

Yes No Don't know

Comments

Who

Liver Disease

Yes No Don't know

Comments

Who

Kidney Disease

Yes No Don't know

Comments

Who

Diabetes (before 55 years old)

Yes No Don't know

Comments

Who

Bed-Wetting (after 10 years old)

Yes No Don't know

Comments

Who

Obesity

Yes No Don't know

Comments

Who

Epilepsy or Convulsions

Yes No Don't know

Comments

Who

Alcohol abuse

Yes No Don't know

Comments

Who

Drug Abuse

Yes No Don't know

Comments

Who

Mental Ilness / Depression

Yes No Don't know

Comments

Who

Developmental Disability

Yes No Don't know

Comments

Who

Immune Problems, HIV, or AIDS

Yes No Don't know

Comments

Who

Tobacco Use

Yes No Don't know

Comments

Who

Additional Family History

PAST HISTORY

Does your child have, or has your child ever had :

Chickenpox

Yes No Don't know

When

Frequent ear infections

Yes No Don't know

Explain

Problems with ears or hearing

Yes No Don't know

Explain

Nasal Allergies

Yes No Don't know

Explain

Problems with eyes or vision

Yes No Don't know

Explain

Asthma, Bronchitis, Bronchiolitis or Pneumonia

Yes No Don't know

Explain

Any Heart Problem or Heart Murmur

Yes No Don't know

Explain

Anemia or bleeding problem

Yes No Don't know

Explain

Blood Transfusion

Yes No Don't know

Explain

HIV

Yes No Don't know

Explain

Organ Transplant

Yes No Don't know

Explain

Malignancy / Bone Marrow Transplant

Yes No Don't know

Explain

Chemotherapy

Yes No Don't know

Explain

Frequent Abdominal Pain

Yes No Don't know

Explain

Constipation requiring doctor visits

Yes No Don't know

Explain

Recurrent urninary tract infection and problems

Yes No Don't know

Explain

Congenital Cataracts / Retinoblastoma

Yes No Don't know

Explain

Metabolic / Genetic disorder

Yes No Don't know

Explain

Cancer

Yes No Don't know

Explain

Kidney Diseas or Urologic Malformations

Yes No Don't know

Explain

Bed-Wetting (after 5 years old)

Yes No Don't know

Explain

Sleep problems; Snoring

Yes No Don't know

Explain

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

Yes No Don't know

Explain

Frequent Headaches

Yes No Don't know

Explain

Convulsions or other neurologic problems

Yes No Don't know

Explain

Obesity

Yes No Don't know

Explain

Diabetes

Yes No Don't know

Explain

Thyroid or other endocrine problems

Yes No Don't know

Explain

High Blood Pressure

Yes No Don't know

Explain

History of Serious Injuries / Fractures / Concussions

Yes No Don't know

Explain

Use of Alcohol or Drugs

Yes No Don't know

Explain

Tobacco Use

Yes No Don't know

Explain

ADHD / Anxiety / Mood Problems / Depression

Yes No Don't know

Explain

Developmental Delay

Yes No Don't know

Explain

Dental Decay

Yes No Don't know

Explain

History of Family Violence

Yes No Don't know

Explain

Sexually Transmitted Infections

Yes No Don't know

Explain

Pregnancy

Yes No Don't know

Explain

(For Girls) Problems with her periods

Yes No Don't know

Explain

Has had first period

Yes No

Age of First Period

Any other significant problems

This American Academy of Pediatrics Initial History Questionnaire is consistent with Bright Futures: Guidelines for Health Supervision of Infants, Children & Adolescents , 3rd Edition

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