Initial History Questionnaire

Child’s Name

Date of Birth

Gender

Male Female

Household

Please list all those living in the child’s home.

Name

Relationship to Child

Birth date

Health Problems

Name

Relationship to Child

Birth date

Health Problems

Name

Relationship to Child

Birth date

Health Problems

Name

Relationship to Child

Birth date

Health Problems

Name

Relationship to Child

Birth date

Health Problems

Name

Relationship to Child

Birth date

Health Problems

Name

Relationship to Child

Birth date

Health Problems

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

If mother and father are not living together or if child does not live with parents, what is the child’s custody status?

If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home?

Birth History

Birth weight

Was the baby born at

Term? Early? Late?

If early, how many weeks gestation?

Did mother have any illness or problem with her pregnancy?

Yes No

Explain

During pregnancy, did mother: (Check all that apply)

Smoke

Drink Alcohol

Use Drugs or Medication

What

When

Was the delivery

Vaginal? Cesarean?

If cesarean, why?

Did your baby have any problems right after birth?

Yes No

Explain

Was initial feeding

Breast? Bottle?

Did your baby go home with mother from the hospital?

Yes No

Explain

General (Check Yes or No)

Do you consider your child to be in good health?

Yes No

Explain

Does your child have any serious illness or medical condition?

Yes No

Explain

Has your child had serious injuries or accidents?

Yes No

Explain

Has your child had any surgery?

Yes No

Explain

Has your child ever been hospitalized?

Yes No

Explain

Is your child allergic to any medicines or drugs?

Yes No

Explain

Development (Check Yes or No)

Are you concerned about your child’s physical development?

Yes No

Explain

Are you concerned about your child’s mental or emotional development?

Yes No

Explain

Are concerned about your child’s attention span?

Yes No

Explain

If your child is in school:

Name of School

Current Grade

How is his/her behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing in academic subjects?

Is he/she in special or resource classes?

Family History (Check Yes or No)

Have any family members had the following

Deafness

Yes No

Who

Comments

Nasal allergies

Yes No

Who

Comments

Asthma

Yes No

Who

Comments

Tuberculosis

Yes No

Who

Comments

Heart disease (before 50yrs)

Yes No

Who

Comments

High blood pressure (before 50yrs)

Yes No

Who

Comments

High cholesterol

Yes No

Who

Comments

Anemia

Yes No

Who

Comments

Bleeding disorder

Yes No

Who

Comments

Liver disease

Yes No

Who

Comments

Kidney disease

Yes No

Who

Comments

Diabetes (before 50 yrs)

Yes No

Who

Comments

Bed-wetting (after 10 yrs)

Yes No

Who

Comments

Epilepsy or convulsions

Yes No

Who

Comments

Alcohol abuse

Yes No

Who

Comments

Drug abuse

Yes No

Who

Comments

Mental illness

Yes No

Who

Comments

Mental retardation

Yes No

Who

Comments

Immune problems, HIV, or AIDS

Yes No

Who

Comments

Additional family history

Patient Medical History (Check Yes or No)

Does your child have, or has he/she ever had

Chickenpox

Yes No

When

Frequent ear infections

Yes No

Explain

Problems with ears or hearing

Yes No

Explain

Nasal allergies

Yes No

Explain

Problems with eyes or vision

Yes No

Explain

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No

Explain

Any heart problem or heart murmur

Yes No

Explain

Anemia or bleeding problem

Yes No

Explain

Blood transfusion

Yes No

Explain

Frequent abdominal pain

Yes No

Explain

Constipation requiring doctor visits

Yes No

Explain

Bladder or kidney infection

Yes No

Explain

Bed-wetting (after 5yrs)

Yes No

Explain

(For girls) Has she started her menstrual periods?

Yes No

Explain

(For girls) Are there problems with her periods?

Yes No

Explain

Any chronic or recurrent skin problem (acne, eczema, etc)

Yes No

Explain

Frequent headaches

Yes No

Explain

Convulsions or other neurologic problem

Yes No

Explain

Diabetes

Yes No

Explain

Thyroid or other endocrine problem

Yes No

Explain

Any other significant problem

Yes No

Explain

Use of alcohol or drugs

Yes No

Explain

Form Completed By

Date Completed

Relationship to Patient

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