Health History Questionnaire

Patient Name:

First Name:

Middle Initial:

Last Name:

Date of Birth:

Please complete the following as best you can prior to visit:

A. PREGNANCY & BIRTH

1. Any problems with the pregnancy, labor or delivery?

Yes No

Delivery

Vaginal Cesarean

2. Was the baby premature?

Yes No

If yes, how many weeks was the pregnancy?

Weeks

3. Birth weight

Ibs:

oz:

4. Was the baby breech?

Yes No

5. Did your baby have any medical problems while in the hospital as a newborn?

Yes No

Please explain:

6. Did the baby stay in the hospital longer than the mother?

Yes No

If yes, why?

B. PAST MEDICAL HISTORY

1. Has your child ever been hospitalized?

Yes No

2. Any surgeries?

Yes No

If yes, describe:

3. Any allergies to foods or medication?

Yes No

If yes, please explain:

4. Is your child currently on medication?

Yes No

If yes, please list:

5. Any serious accidents, broken bones, stitches?

Yes No

If yes, please explain:

6. Any chronic medical problems e.g. asthma, allergies, diabetes, seizures, cystic fibrosis, urinary tract infection, ear infections?

Yes No

Please explain:

C. IMMUNIZATIONS

If you have your child's immunization records, please give it to the nurse or receptionist.

1. Is your child behind on his or her immunizations?

Yes No

Please explain:

2. Any previous reactions to immunizations?

Yes No

Please explain:

D. FEEDING

1. Was the baby breast fed or bottle fed?

If breast fed, for how long?

2. Is your child still on a bottle?

Yes No

E. SOCIAL

1. Is your child in daycare?

Yes No

2. Does anyone in your home smoke?

Yes No

3. Do you have any firearms in your home?

Yes No

If yes. are they locked and unloaded?

Yes No

4. Do you live or visit regularly a house built before 1978 (including daycare)?

Yes No

5. Do you have pets at home?

Yes No

If so. what kind:

6. Do members of the household travel to foreign countries?

Yes No

If so, name the countries:

7. Who lives at home with your child?

F. DEVELOPMENT & GENERAL MANAGEMENT

1. Do you have any problems managing your child?

Yes No

2. Does your child have any difficulties in school?

Yes No

3. Is your child in a special class?

Yes No

4. What grade is your child in?

5. Have you been concerned with your child's development?

Yes No

G. FAMILY HISTORY

2. Does the child's mother have any health problems?

Yes No

If yes, explain:

3. Does the child's father have any health problems?

Yes No

If yes, explain:

4. Has either parent ever had any serious illness?

Yes No

If yes, explain:

5. List ages, sex, and general health of your child's brothers and sisters:

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Parent Signature:

Date:

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