Medical / Family History Questionnaire

Maryland Healthy Kids Program

Patient Name

Date of Birth

Sex

Male Female

Form Complete By

Today's Date

Relationship

PREGNANCY AND BIRTH HISTORY

Name of Hospital

Illness during pregnancy?

Yes No

Medications during pregnancy?

Yes No

Alcohol / Drug Abuse?

Yes No

Problems at birth?

Yes No

Describe

Type of delivery?

Vaginal

C-section

Birth Weight

Discharge Weight

Did baby receive Hepatitis B vaccine?

Yes No

Date of Hepatitis B immunization

PSYCHOSOCIAL HISTORY

Who lives in household?

How many?

Type

Rent?

Own?

Shelter?

Who cares for child?

Date of Birth?

Mother

Father

Are parents working?

Mother

Yes No

Father

Yes No

Foster Care?

Dates

Other Languages?

FAMILY HISTORY

Has anyone in the family (parents, grand-parents, aunts/uncles, sisters/brothers) had:

Who?

Allergies

Yes No

Allergies (List)

Asthma

Yes No

TB/Lung Disease

Yes No

HIV / AIDS

Yes No

Suicide Attempts

Yes No

Heart Disease

Yes No

High Blood Pressure / Stroke

Yes No

High Cholesterol

Yes No

Blood Disorders / Sickle Cell

Yes No

Diabetes

Yes No

Seizures

Yes No

Mental Illness

Yes No

Cancer

Yes No

Birth Defects

Yes No

Hearing Loss

Yes No

Speech Problems

Yes No

Kidney Problems

Yes No

Alcohol / Drug Abuse

Yes No

Hepatitis / Liver Disease

Yes No

Thyroid Disease

Yes No

Learning Problems/Attention Deficit Disorder

Yes No

Family Violence

Yes No

Other

MEDICAL HISTORY

Has your child ever had

Allergies

Yes No

Allergies (List)

Asthma

Yes No

Chicken Pox

Yes No

Chicken Pox (Year)

Frequent Ear Infections

Yes No

Vision/Hearing Problems

Yes No

Skin Problems/Eczema

Yes No

TB / Lung Disease

Yes No

High Blood Pressure

Yes No

Heart Defects / Disease

Yes No

Liver Disease / Hepatitis

Yes No

Diabetes

Yes No

Kidney Disease / Bladder Infections

Yes No

Physical or Learning Disabilities

Yes No

Bleeding Disorders / Hemophilia

Yes No

Sexually Transmitted Disease

Yes No

Emotional or Behavioral Problems

Yes No

Depression / Suicidal Thoughts

Yes No

Hospitalizations / Surgeries

Yes No

Physical/Emotional/Sexual Abuse

Yes No

Bone or Joint Injuries

Yes No

Obesity/Eating Disorders

Yes No

Other

Current Medication(s): (List)

Reviewed by

Date of Review

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