Tri County Pediatrics Questionnaire Form

Patient's Name

Date of Birth

Relationship to Patient

Please Select Yes or No, explain where required. N/A - Not Applicable

Pregnancy & Birth

Mothers Health During Pregnancy?

Medications During Pregnancy?

Yes No

Hospital Name

Gestation Weeks

Type of Delivery?

C-Section Vaginal

Birth Weight

Newborn Hearing Test

Passed Failed

HEP B Vaccine given at birth?

Yes No

Complications?

Yes No

Breech?

Yes No

Problems with baby during birth

Jaundice?

Yes No

Smoking, Alcohol, Street drugs, during pregnancy?

Yes No

Child's Past Medical History

Allergies to Medicine?

Yes No

Food?

Yes No

Any Surgeries?

Yes No

Immunizations up to date?

Yes No

Hospitalization (when, where, why)?

Serious Injuries (when, where)?

Asthma

Yes No

Allergic Rhinitis

Yes No

Ear Infection

Yes No

Eczema/Hives

Yes No

Autism

Yes No

Seizures

Yes No

UTI / Genital Urinar

Yes No

Speech Delay

Yes No

Blood Disorder

Yes No

Neurological / CP

Yes No

Vision Problems

Yes No

Hearing Problems

Yes No

Joint Problems

Yes No

Skin Problems

Yes No

Developmental Problems

Yes No

Heart Problems

Yes No

Abdominal Problems

Yes No

ADD/ADHD/Psychiatric

Yes No

Depression

Yes No

Kidney Problem

Yes No

Nutrition

Appetite usually good?

Yes No

Colic or feeding problems during first 3 months?

Yes No

Breast fed?

Yes No

Formula

Yes No

Brand

Drinks Milk?

Yes No

Eats Fruit?

Yes No

Eats Vegetables?

Yes No

Social History

Language Spoken at home

English Spanish Other

If other, please indicate

Child Lives with

Mother Father Both Grandmother Aunt Guardian

Father/Mother Involved

Yes No

Smokers at home?

Yes No

Pets?

Yes No

Development & Behavior

Age at which child:

Sat Alone

Walked

Used Sentences / Speech

Teeth

School Age Child

Grade in school

Likes School

Yes No

Problems in school?

Yes No

Learning Problems?

Yes No

Behavior Problems?

Yes No

Bad Habits?

Yes No

Bedwetting?

Yes No

Sleeping well

Yes No

Smoking?

Yes No

Use street or illegal drugs?

Yes No

Any Hobbies or sports?

Family Medical History

List all blood relatives of your child who have had the following problems:

Allergies

Asthma

Allergic Rhinitis

Eczema

Blood Disorder

Mental Illness

Drug Problem

Cancer

Arthritis/Hip Disorder

Epilepsy/Seizures

Heart Disease/Cholesterol Problem

High Blood Pressure

Migraine

Deafness

Diabetes

Stomach Problems

Thyroid Problems

Vision Problems

Explain other concerns

List of Medications

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Date

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