HEALTH HISTORY FORM

Initial History Questionnaire

FORM COMPLETED BY:

DATE COMPLETED

NAME:

ID NUMBER:

BIRTH DATE:

AGE:

SEX:

Male Female

Household

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

Name:

Relationship to child:

Birth Date:

Health Problems:

Add Another Individual

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

Joint custody

Single custody

Lives with foster family

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 know birth history

Birth Weight:

Was the baby born at term?

Yes No

Weeks:

Were there any prenatal or neonatal complications?

Yes No

Explain:

During pregnancy, did mother...

Use tobacco:

Yes No

Drink Alcohol:

Yes No

Use drugs or medications:

Yes No Used prenatal vitamins

What:

When:

Was the delivery:

Vaginal Cesarean

If cesarean, why?

Was initial feeding:

Formula Breast Milk

How long breastfed?

Did your baby go home with mother from the hospital?

Yes No

Explain:

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?

Childhood hearing loss

Yes No DK

Who:

Comments:

Nasal allergies

Yes No DK

Who:

Comments:

Asthma

Yes No DK

Who:

Comments:

Tuberculosis

Yes No DK

Who:

Comments:

Heart disease (before 55 years old)

Yes No Dk

Who:

Comments:

High cholesterol/takes cholesterol medication

Yes No DK

Who:

Comments:

Anemia

Yes No DK

Who:

Comments:

Bleeding disorder

Yes No DK

Who:

Comments:

Dental decay

Yes No DK

Who:

Comments:

Cancer (before 55 years old)

Yes No DK

Who:

Comments:

Liver disease

Yes No DK

Who:

Comments:

Kidney disease

Yes No DK

Who:

Comments:

Diabetes (before 55 years old)

Yes No DK

Who:

Comments:

Bed-wetting (after 10 years old)

Yes No DK

Who:

Comments:

Obesity

Yes No DK

Who:

Comments:

Epilepsy or convulsions

Yes No DK

Who:

Comments:

Alcohol abuse

Yes No DK

Who:

Comments:

Drug abuse

Yes No Dk

Who:

Comments:

Mental illness/depression

Yes No DK

Who:Short text field

Comments:

Developmental disability

Yes No DK

Who:

Short text field

Immune problems, HIV, or AIDS

Yes No DK

Who:

Comments:

Tobacco use

Yes No DK

Who:

Comments:Short text field

Past History

DK = don’t know

Does your child have, or has your child ever had,

Yes No DK

When

Chickenpox

Yes No Dk

Explain

Frequent ear infections

Yes No DK

Explain

Problems with ears or hearing

Yes No DK

Explain

Nasal allergies

Yes NO Dk

Explain

Problems with eyes or vision

Yes No DK

Explain

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No DK

Explain

Any heart problem or heart murmur

Yes No DK

Explain

Anemia or bleeding problem

Yes No DK

Explain

Blood transfusion

Yes No Dk

Explain

Radio buttons

Yes No Dk

Explain

HIV

Yes No DK

Explain

Organ transplant

Yes No DK

Explain

Malignancy/bone marrow transplant

Yes No Dk

Explain

Chemotherapy

Yes No DK

Explain

Frequent abdominal pain

Yes No DK

Explain

Constipation requiring doctor visits

Yes No DK

Explain

Recurrent urinary tract infections and problems

Yes No DK

Explain

Congenital cataracts/retinoblastoma

Yes No Dk

Explain

Metabolic/Genetic disorders

Yes No DK

Explain

Cancer

Yes No DK

Explain

Kidney disease or urologic malformations

Yes No DK

Explain

Bed-wetting (after 5 years old)

Yes No DK

Explain

Sleep problems; snoring

Yes No Dk

Explain

Chronic or recurrent skin problems (eg, acne, eczema)

Yes No DK

Explain

Frequent headaches

Yes No DK

Explain

Convulsions or other neurologic problems

Yes No

Explain

Obesity

Yes No DK

Explain

Diabetes

Yes No DK

Explain

Thyroid or other endocrine problems

Yes No DK

Explain

High blood pressure

Yes No DK

Explain

History of serious injuries/fractures/concussions

Yes No DK

Explain

Use of alcohol or drugs

Yes No DK

Explain

Tobacco use

Yes No DK

Explain

ADHD/anxiety/mood problems/depression

Yes No Dk

Explain

Developmental delay

Yes No DK

Explain

Dental decay

Yes No DK

Explain

History of family violence

Yes No DK

Explain

Sexually transmitted infections

Yes No DK

Explain

Pregnancy

Yes No DK

Explain

(For girls) Problems with her periods

Yes No DK

Explain

Has had first period

Yes No

Age of first period

Any other significant problem

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