Initial History Questionnaire

FORM COMPLETED BY

DATE COMPLETED

Name

ID NUMBER

BIRTH DATE

AGE

SEX

M F

Household

Please list all those living in the child’s home

Add Child

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

What is the child’s living situation if not with both biological parents?

Lives with adoptive parents Lives with foster family Joint custody Single custody

If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?

Birth History

Don't t know birth history

Add new row

General

DK = don’t know

Do you consider your child to be in good health?

Yes No DK

Explain

Does your child have any serious illnesses or medical conditions?

Yes No DK

Explain

Has your child had any surgery?

Yes No DK

Explain

Has your child ever been hospitalized?

Yes No DK

Explain

Is your child allergic to medicine or drugs?

Yes No DK

Explain

Do you feel your family has enough to eat?

Yes No DK

Explain

Biological Family History

DK = don’t know

Have any family members had the following?

Who

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Additional family history

Past History

DK = don’t know

Does your child have, or has your child ever had

When

Explain

Has had first period

Yes No

Age of first period

Any other significant problem

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

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