New Patient Health Questionnaire

Paitent's Name:

DOB:

Mother's Name:

Age:

Father's Name:

Age:

Who does the Patient live with?

Who is the patient’s legal guardian?

Pregnancy Questions

Please List Any Problems During the Pregnancy

Did the mother take any medications other than vitamins and irons during pregnancy?

Where was baby born? Mother's age at birth?

How was baby delivered?

Were there in problems with the delivery or in the nursery?

Past Medical Care

Where has the patient gone for past medical care?

List any chronic problems with patient.

Please list any hospitalizations. When, why & where?

Please list all surgeries the patient has had.

Has the patient had a fractured bone, knee injuries or chronic joint pain?

Has the patient had any other traumatic injury?

Please list all medications the patient is on.

Is the patient allergic to any medications or foods? If yes, please list.

Has the patient had any reactions to immunizations?

Family/Social History

Do any siblings, parents, gparents, aunts, uncles or cousins have AIDS/HIV or other immunodeficiency?

Are any siblings, parents, gparents, aunts, uncles or cousins undergoing immunosuppression or receiving treatment for cancer?

Do any siblings, parents, gparents, aunts, uncles or cousins have asthma, hay fever or eczema?

Is the patient exposed or in contact with someone with TB?

Do any siblings, parents, gparents, aunts, uncles or cousins have diabetes?

Do any siblings, parents, gparents, aunts, uncles or cousins have sudden death before 40 unexplained, passing out or heart problems?

Do any siblings, parents, gparents, aunts, uncles or cousins have inherited disease?

Have any siblings or other children living with the family been told they have a high level of lead?

Is the patient exposed to smoke in the house?

Does your house have smoke detectors and carbon monoxide detectors?

How did you hear about the practice?

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