Initial History Questionnaire
Patient Name:
First Name
Last Name
Person Who Filled Out Form:
Date Filled Out:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex:
Male
Female
Relationship to Patient:
PREGNANCY AND BIRTH HISTORY
Is the child adopted?
Yes
No
Birth Weight: (pounds)
Birth Weight: (ounces)
Was baby born on time?
Yes
No
# of weeks
Was the birth:
Vaginal
C-Section
If C-Section,Why?
Were there any problems during the pregnancy or at birth?
Yes
No
If yes, explain:
During pregnancy did mom:
Use tobacco?
Yes
No
Drink alcohol?
Yes
No
Use drugs or other medications?
Yes
No
What:
Use prenatal vitamins?
Yes
No
When:
Did baby have problems or need to stay in a NICU?
Yes
No
If yes, explain:
The initial feeding for the baby was:
Formula
Breast milk
How long did the baby breastfeed?
Did the baby go home with mom?
Yes
No
If no, explain:
CHILD’S HEALTH HISTORY
Has the child ever had:
Rows
Yes
No
Hospitalizations
Serious Injuries/Broken Bones
Surgeries
Allergies To Medications/Other:
Chicken Pox
Frequent Ear Infections
Vision/Hearing Problems
Nasal Allergies
Asthma /Lung Problems
Tuberculosis(TB)/Risks for TB
Any Heart Problems/Murmur
Anemia/Sickle Cell
Bleeding Problems/Transfusion
Immune Problems/HIV
Cancer
Stomach Aches/Constipation
Bladder Infections/Kidney Disease
Birth Defects
Metabolic/Genetic Conditions
Sleep/Snoring/Bed Wetting Issues
Chronic Skin Problems/Eczema
Frequent Headaches
Seizures/Neurological Problems
Obesity
Diabetes
Thyroid/Endocrine Problems
High Blood Pressure
Alcohol/Drug Use/Tobacco
ADHD/Anxiety/Mood/Depression
Developmental Delay/Disability
Dental Decay/Cavities
History of Family Violence/Abuse
Sexual Infections/Pregnancy
Elevated Lead Level
Other:
HOUSEHOLD
List names, relationships to child, and ages of all people living with the child:
Are there siblings not listed? If so, list names, ages and where they live:
What is your child’s living situation?
Joint custody
Single custody
Foster care
If one or both parents are not living in the home, how often does the child see the parent not in the home?
Tobacco use in family
Yes
No
Who?
BIOLOGICAL FAMILY
HEALTH HISTORY
Has anyone in the family of the child (parents, grandparents, sisters/brothers) had:
Rows
Yes
No
Who?
Childhood Hearing Loss
Nasal Allergies
Asthma
Tuberculosis (TB)/Risks for Tuberculosis
Lung Problems
Heart Disease
High Blood Pressure/Stroke
High Cholesterol/Takes
Cholesterol Medication
Anemia/Sickle Cell
Bleeding Problems
Dental Decay (cavities)
Cancer
Liver Disease/Hepatitis
Kidney Disease
Diabetes (high blood sugar)
Obesity
Seizures/Epilepsy
Alcohol Abuse
Drug Abuse
Mental Illness/Depression
Development Delay/Disability
Immune Problems/HIV/AIDS
Other Family History:
Additional Comments:
Submit
Should be Empty: