Pediatrics Questionnaire

PEDIATRIC QUESTIONNAIRE
Parent/Legal Guardian

Enter Name of person answering the following questions:
Primary Cellphone
Please enter a valid phone number.Format: (000) 000-0000.
First and Last Name, Relationship to Child

Completed by (Name)Relation to child
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Has your child received Dental Care?
Had your child received an Eye Exam
Is your child adopted?
Where was your child adopted from:
Any illness during pregnancy?
Any medications during pregnancy?
Any of the following during pregnancy? Check all that apply.
Was baby delivered:
If early or late, please specify how early or late the baby was delivered.
Complications during delivery?
Apgar Scores:
Were there any problems with baby at birth?
Jaundice
Any other information you would like to share with us regarding pregnancy and birth?
Past Medical History
Allergies to medicine?
If Yes, please list medications your child is allergic to:
Allergies to food, dust, pollen, insect stings?
If Yes, please list what your child is allergic to:
Please list any mediations you child takes on a regular basis.
Has your child been hospitalized or had surgery?
Please list the Date/City/State/Hospital/Reason for each instance.
Please check if your child has any of the following:
Please provider the following: a date if your child had chicken pox, what the serious injury was if applicable, and anything else you would like us to know about your child's health:
Feeding and Nutrition
Is your child's appetite usually good?
Colic or feeding problems during the first 3 months?
Breast fed?
How many months did you breastfeed?
Formula?
Current Brand?
Vitamins?
Brand?
Fluoride?
Does your child drink fluoridated water?
Family Profile
Parents
Mother's Name

First NameLast Name
Mother's DOB

MonthDayYear
Highest School Grade
Occupation
Employer
Health
Father's Name

First NameLast Name
Father's DOB

MonthDayYear
Highest School Grade
Occupation
Employer
Health
Siblings

List the child's sisters and brothers
Name

First NameLast Name
DOB

MonthDayYear
Name

First NameLast Name
DOB

MonthDayYear
Name

First NameLast Name
Date

MonthDayYear
Name

First NameLast Name
Date

MonthDayYear
Name

First NameLast Name
Date

MonthDayYear
Have any of your children died?
Family Medical History
List all blood relatives of your child who have had the following problems - use abbreviation (F) Father, (M) Mother, (B) Brother, (S) Sister, (MM) Mother's Mother, (MF) Mother's Father, (FM) Father's Mother, (FF) Father's Father, (A) Aunt, (U) Uncle, (C) Cousin
Anemia/Blood Disorder
Asthma/Allergies
Intellectual Disability
Drug Problem
Alcoholism
Cancer
Sudden Infant Death
Cystic Fibrosis
Muscular Dystrophy
Tuberculosis
Arthritis/Lupus
Epilepsy/Seizures
Early Diabetes
Early Deafness
Birth Defects
AIDS
High Blood Pressure
High Cholesterol
Migraines
Heart Disease
Kidney Disease
Emotional Problems
Thyroid Disease
Inherited Disease
Other
Safety/Environment
Do you live in:
Do you know the hottest temperature of the water in your pipes?
Set your water heater thermostat so that the hottest temperature at the faucet is 120 degrees F to help avoid scald burns.
Is there a working smoke alarm on each floor in the house?
Does your child always use a car seat/seatbelt in the car?
Are there smokers in the household?
Are there any problems with the condition of your home?
Does your house have a pool?
Are there firearms in your home?
Development & Behavior

Age at which child:
Sat alone
Walked
Used sentences
Toilet trained
Bicycled
Development compared to other children?
Grade in school
Problems in school?
Learning problems?
If yes, please list any concerns you have regarding your child's learning.
Getting along with other children?
If yes, please explain.
Behavior problems?
If Yes, please list any concerns you have regarding your child's behavior.
Bad Habits?
If yes, please explain.
Bedwetting?
Nail biting?
Problems sleeping?
Please list hobbies, sport(s), social activities your child participates in.
Use of street or illegal drugs?
Please list any other mental health problems you may be concerned about.
Are there any particular problems or stresses for your family now such as marriage dificulties, job/financial problems, family illness, problems with other children?
I hearby give my permission for my child to receive medical care in the case of an emergency in the event I can not be reached.
Date

MonthDayYear
Signature of Parent/Legal Guardian
Form Disclosure

By submitting this form, you agree that [Practice Name] may use the information you provide to respond to your request and, where applicable, to contact you about your child's care. We do not sell your information. View our full Privacy Policy at https://www.rtcpeds.com/privacy-policy.
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PEDIATRIC QUESTIONNAIRE

Parent/Legal Guardian

Past Medical History

Feeding and Nutrition

Family Profile

Siblings

Family Medical History

Safety/Environment

Set your water heater thermostat so that the hottest temperature at the faucet is 120 degrees F to help avoid scald burns.

Development & Behavior