Pediatrics Questionnaire

PEDIATRIC QUESTIONNAIRE
Parent/Legal Guardian

Enter Name of person answering the following questions:
Primary Cellphone*
Please enter a valid phone number.
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?

YesNo
Had your child received an Eye Exam

YesNo
Is your child adopted?

YesNo
Where was your child adopted from:
Any illness during pregnancy?

YesNo
Any medications during pregnancy?

YesNo
Any of the following during pregnancy? Check all that apply.

SmokingAlcoholStreet Drugs
Was baby delivered:

Early?Late?On time?
If early or late, please specify how early or late the baby was delivered.
Complications during delivery?

YesNo
Apgar Scores:
Were there any problems with baby at birth?

YesNo
Jaundice

YesNo
Any other information you would like to share with us regarding pregnancy and birth?
Past Medical History
Allergies to medicine?

YesNo
If Yes, please list medications your child is allergic to:
Allergies to food, dust, pollen, insect stings?

YesNo
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?

YesNo
Please list the Date/City/State/Hospital/Reason for each instance.
Please check if your child has any of the following:

anemia/sickle cell diseaseasthma/wheezingbleeding tendencyblood transfusionsbronchitis/pheumoniachicken poxconstipation/diarrheadiabeteseating problemseye problemsfrequent coldsfrequent ear infectionsfrequent feversfrequent sore throatsfrequent stomach acheshayfever/allergieshearing/speech problemheart problemsherniahip/leg/foot problemskidney/bladder problemsloss of consciousnessmigraines/headachesskin problems/hives/eczemaseizures/confulsionsserious injuryturberculosis
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?

YesNo
Colic or feeding problems during the first 3 months?

YesNo
Breast fed?

YesNo
How many months did you breastfeed?
Formula?

YesNo
Current Brand?
Vitamins?

YesNo
Brand?
Fluoride?

YesNo
Does your child drink fluoridated water?

YesNo
Family Profile
Parents

MarriedSeparatedDivorced
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?

YesNo
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:

A private home?Apartment?Mobile home?Other?
Do you know the hottest temperature of the water in your pipes?

YesNo
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?

YesNo
Does your child always use a car seat/seatbelt in the car?

YesNo
Are there smokers in the household?

YesNo
Are there any problems with the condition of your home?

Peeling PaintInsectsRatsMice
Does your house have a pool?

YesNo
Are there firearms in your home?

YesNo
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?

YesNo
Learning problems?

YesNo
If yes, please list any concerns you have regarding your child's learning.
Getting along with other children?

YesNo
If yes, please explain.
Behavior problems?

YesNo
If Yes, please list any concerns you have regarding your child's behavior.
Bad Habits?
If yes, please explain.
Bedwetting?

YesNo
Nail biting?

YesNo
Problems sleeping?

YesNo
Please list hobbies, sport(s), social activities your child participates in.
Use of street or illegal drugs?

YesNo
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*

Clear
Should be Empty:

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