Patient History Questionaire

Patient's Name

Date of Birth

Age Today

Today's Date

Reason for today's visit

Do you have a record of this child's immunizations with you today?

Yes No

Please indicate answers by filling in the blanks or choosing yes or no. Answer only the questions which apply to your child's age.

Mother's Name

Birthdate

Occupation

Cultural background of mother

Father's Name

Birthdate

Occupation

Cultural background of father

If adults in the househod work outside the home, what childcare arrangements are made for this child?

Pregnancy and Birth

Mother's Age at Birth of Child

Did mother have any illness during pregnancy?

Yes No

Did she take any medications other than vitamins and iron?

Yes No

Was the Baby on Time?

Yes No

Was the birth by C-Section or vaginal?

C-Section Vaginal

Obstetrician's Name

Pediatrician who saw the baby in the hospital

What was the birth weight?

What was the birth height?

Did the baby have any trouble starting to breathe?

Yes No

Did the baby receive Hepatitis B vaccine in the nursery?

Yes No

Did the baby have any problems while in the hospital? (Jaundice, infections, other?)

Yes No

If yes, what kind?

Safety/Environment

Do you live in a

Private House Apartment Mobile Home Other

Do you know the hottest temperature of water in your pipes?

Yes No

Is there a working smoke alarm on each floor in the home?

Yes No

Is there a working fire extinguisher in the home?

Yes No

Does this child always use a car seat/seat belt when in a car?

Yes No

Are there smokers in the house?

Yes No

Are there any problems with the condition of your home? (Peeling paint, insects, rats, or mice?)

Yes No

Does your child always wear a helmet when riding a bicycle?

Yes No

Are there pets in the home?

Yes No

If yes, how many and what type?

Family History

Are the child's parents both in good health?

Yes No

Use this space to note which relative has which disease

Have any siblings died?

Yes No

If yes, cause of death

Please list:

Sibling Name

Birthdate

Sex

General Health (Problems)

Sibling Name

Birthdate

Sex

General Health (Problems)

Sibling Name

Birthdate

Sex

General Health (Problems)

Sibling Name

Birthdate

Sex

General Health (Problems)

Who currently lives in the household?

Feeding and Nutrition

Current Nutrition

breast fed

formula fed

table food

If formula fed, which one?

Amount in oz

If on regular milk, which one?

Amount/day

Is your child's appetite usually good?

Yes No

Do any foods disagree with him/her?

Yes No

Is it good now?

Yes No

For the first 6 months was this child:

breast fed bottle fed

Was there severe colic or any other unusual feeding?

Yes No

Does s/he take vitamins/fluoride?

Yes No

Which ones?

Development/Behavior

At what age did this child sit alone?

At what age did s/he walk alone?

Did s/he say any words by the 18months of age?

Yes No

How does this child compare to others his or her age?

Same Advanced Behind

Are there any problems with sleeping?

Yes No

What grade is this child in?

Has s/he had any trouble with school?

Yes No

Does s/he get along well with other children?

Yes No

Pas Medical History

Where has your child gone for check-ups until now?

Date of last check up

Date of last dental check-up

Has your child had any allergic reactions to any medications, foods, or insect bites?

Yes No

Which ones

Has your child had a bad reaction to any immunizations?

Yes No

Which ones

Any hospitalizations/surgeries other than for birth?

Yes No

For what?

Any serious injuries/broken bones/stitches?

Yes No

What kind?

Are there any medications taken regularly?

Yes No

Which ones?

Review of Systems

Has your child had frequent ear infections?

Yes No

Any hearing problems?

Yes No

Any vision problems?

Yes No

Has s/he had any problems with teeth?

Yes No

Does this child have frequent colds or sore throat?

Yes No

Does s/he have a history of

allergies

pneumonia

bronchitis

recurrent cough

Does s/he have a heart mumur or an heart problerm?

Yes No

Any problems with kidney's, bladder or urination?

Yes No

Any problems with diarrhea or constipation?

Yes No

Have there been any convulsions or other problems with the nervous system?

Yes No

Any eczema, hives, or other skin conditions?

Yes No

Has your child ever been anemic?

Yes No

Has your child ever seen a specialist?

Yes No

If yes, for what problems?

Your information will be encrypted.