Initial History Questionnaire
FORM COMPLETED BY
DATE COMPLETED
-
Month
-
Day
Year
Date
Name
First Name
Last Name
ID NUMBER
BIRTH DATE
-
Month
-
Day
Year
Date
AGE
GENDER:
Male
Female
Household
Please list all those living in the child’s home.
Rows
Name
Relationship to child
Birthdate
Health Problems
1
2
3
4
5
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? OR weeks
Were there any prenatal or neonatal complications?
Yes
No
Explain
Was a NICU stay required?
Yes
No
Explain
During pregnancy, did mother
Use tobacco
Yes
No
Drink alcohol
Yes
No
Use drugs or medications
Yes
No
Used prenatal vitamins
Yes
No
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?
Rows
Yes
No
DK
Who
Comments
Childhood hearing loss
Nasal allergies
Asthma
Tuberculosis
Heart disease (before 55 years old)
High cholesterol/takes cholesterol medication
Anemia
Bleeding disorder
Dental decay
Cancer (before 55 years old)
Liver disease
Kidney disease
Diabetes (before 55 years old)
Bed-wetting (after 10 years old)
Obesity
Epilepsy or convulsions
Alcohol abuse
Drug abuse
Mental illness/depression
Developmental disability
Immune problems, HIV, or AIDS
Tobacco use
Additional family history
Past History
DK = don’t know
Does your child have, or has your child ever had,
Rows
Yes
No
DK
Explain
Chickenpox
Frequent ear infections
Problems with ears or hearing
Nasal allergies
Problems with eyes or vision
Asthma, bronchitis, bronchiolitis, or pneumonia
Any heart problem or heart murmur
Anemia or bleeding problem
Blood transfusion
HIV
Organ transplant
Malignancy/bone marrow transplant
Chemotherapy
Frequent abdominal pain
Constipation requiring doctor visits
Recurrent urinary tract infections and problems
Congenital cataracts/retinoblastoma
Metabolic/Genetic disorders
Cancer
Kidney disease or urologic malformations
Bed-wetting (after 5 years old)
Sleep problems; snoring
Chronic or recurrent skin problems (eg, acne, eczema)
Frequent headaches
Convulsions or other neurologic problems
Obesity
Diabetes
Thyroid or other endocrine problems
High blood pressure
History of serious injuries/fractures/concussions
Use of alcohol or drugs
Tobacco use
ADHD/anxiety/mood problems/depression
Developmental delay
Dental decay
History of family violence
Sexually transmitted infections
Pregnancy
(For girls) Problems with her periods
Has had first period
Yes
No
Age of first period
Any other significant problem
Submit
Should be Empty: