Parent Questionnaire for New Patients

Tri-State Developmental Pediatrics

Please correct the errors described below.

This questionnaire gives you a chance to tell us about your child. We want to know about your concerns and worries so that we can try to help. Knowing about things like your child’s health, past experiences, and family history can help us help your child. The questionnaire should be completed by the person who takes care of the child most of the time. There is no right or wrong answer. Answer each question to the best of your ability. If you do not know the answer, make notes of what you do know. We need this form before we can schedule your child’s appointment. All information is kept strictly confidential.

Educational Services

Health History



What medicines, vitamins, and nutrition supplements does your child take each day?

Add Another Medication

Has your child taken medicines to treat chronic health or behavior problems in the past?

Add Another Medication

Pregnancy and Birth History

The following questions are about the pregnancy with the child being evaluated.

Labor and Delivery

Developmental History

Has your child experienced any of the following?

For children in the care of a relative, adoptive or foster parent, or someone who is NOT the biological parent…

Family History

Please indicate if someone in the child’s biological family has any of the following disorders

Your information will be encrypted.