Medical History Questionnaire

Please complete one copy for EACH child:
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
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 with the child, how often does he/she see the parent/parents whom they do not live with?
Delivery was:
If delivery was cesarean, what was the reason?
Did your baby have any problems right after birth? If yes, Why?
Did your baby go home from the hospital with mother? If no, please explain:
Gestational Age at Birth
Birth Weight
Hospital of Birth
Did the mother experience illness during the pregnancy? If yes, please explain:
During the pregnancy, did the mother:

SmokeDrink alcoholUse recreational drugsRequire medication
If the mother used recreational drugs or medications during pregnancy, please explain:
Does your child have any serious illness or medical condition, or had any serious injuries or accidents? Please explain:
Has your child had any surgeries? If yes, please explain:
Has your child ever been admitted to a hospital? If yes, please explain:
Is your child allergic to any medications or foods? If yes, please explain (both name of medication/food and reaction):
Are you concerned about your child's physical development? If yes, please explain:
Are you concerned about your child's mental or emotional development? If yes, please explain:
If your child is in school, how is their behavior/academic progress:
Has your child failed or repeated a grade in school? If yes, please explain:
Is your child in Birth to 3, Occupational/Physical Therapy, getting Resource Room help or in a Special Education Class? If yes, please explain:
Does your child have, or ever had (multiple choices possible):

Chicken PoxFrequent Ear InfectionsHearing lossVision problemsNasal allergiesAsthmaBronchiolitisPneumoniaHeart murmurAnemiaBleeding problemHad a blood transfusionFrequent abdominal painConstipation requiring doctor visitsBladder or kidney infectionBedwetting (after age 8)EczemaAcneFrequent headachesSeizuresThyroid or other endocrine problemDrug or alcohol addictionMenstrual cramps or other period related issuesAnxietyDepressionADHDEating disorderOther
Please list any other medical conditions not listed, and elaborate on any diagnoses noted above:
Is your child on any regular medications? If yes, please list:
Is there a family history of any of the following? (multiple options possible)

DeafnessParent or sibling needing glasses prior to age 10AsthmaHeart disease (prior to age 50)Heart arrhythmiaAnemiaBleeding disorderLiver diseaseKidney diseaseEndocrine diseaseAutoimmune disorderDiabetesEpilepsyDrug abuseMental illnessLearning disabilityImmune deficiencyCancerGenetic disorderFrequent ear infectionsOther
If you answered yes to any of the above, please provide details on which family member has/had the illness, and if cancer, specify type:
Should be Empty: