Initial Patient History Form
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Form Completed by / Relationship to patient
*
Household Please list all adults and children living in the child's home.
*
Rows
Name
Relationship to Child
Birth Date
Notes
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Birth History Birth Weight
*
Was the baby born:
*
At term
Late
Unknown
Early (If early, list weeks of gestation below)
Did mother have any illnesses or problems with her pregnancy?
*
No
Unknown
Yes (please explain below)
During pregnancy, did mother:
*
Rows
Yes/No/DK
What
When
Smoke
Yes
No
Don't Know
Drink Alcohol
Yes
No
Don't Know
Use drugs or medications
Yes
No
Don't Know
Was the delivery vaginal or Caesarean? If Caesarean, why?
*
Vaginal
Unknown
Caesarean (explain below)
Did your baby have any problems right after birth?
*
No
Unknown
Yes (please explain below)
Was initial feeding
*
Breast
Bottle
Unknown
Did your baby go home with mother from the hospital?
*
Yes
Unknown
No (please explain below)
General
*
Rows
Yes/No/DK
If Yes, pleas explain
Has your child had any broken bones, serious injuries, concussion?
Yes
No
Don't Know
Does your child have any new serious illness or medical condition?
Yes
No
Don't Know
Has your child had any Emergency Room visits?
Yes
No
Don't Know
Has your child had any operations or been hospitalized?
Yes
No
Don't Know
Does your child take any medications or supplements?
Yes
No
Don't Know
Is your child allergic to any medications, foods, bee stings, cats/dogs?
Yes
No
Don't Know
Development
*
Rows
Yes/No
If Yes, pleas explain
Are you concerned about your child's physical development?
Yes
No
Are you concerned about your child's mental or emotional development?
Yes
No
Are you concerned about your child's attention span?
Yes
No
Is your child in school?
*
Yes
No
How is his/her behavior in school?
*
Are you concerned about your child's school performance?
*
Has he/she failed or repeated a grade in school?
*
How is he/she doing in academic subjects?
*
Is he/she in a special or resource class?
*
Did/do you or any of the child's relatives have any of the following? (If YES, please identify relative)
*
Rows
Yes/No/DK
Family Member
Comments
Allergies
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Asthma/Wheezing
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Cardiac (heart) problems
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Fainting
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Sudden Death (before age 60)
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Stroke/Blood Clots
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
High cholesterol
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
High Blood Pressure
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Diabetes
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Obesity
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Did/do you or any of the child's relatives have any of the following? (If YES, please identify relative)
*
Rows
Yes/No/DK
Family Member
Comments
Bleeding Tendency
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Cancer (Please specify type)
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Scoliosis
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Dev Hip Dysplasia
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Eczema or Psoriasis
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Arthritis
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Thyroid
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Stomach or Intestinal problems
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Kidney/Renal disease
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Migraines
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Did/do you or any of the child's relatives have any of the following? (If YES, please identify relative)
*
Rows
Yes/No/DK
Family Member
Comments
Seizures
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Hearing Loss
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Vision problems
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Mental retardation
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Developmental delays
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Autism
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Sleep Disorder
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
School problem
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Learning disability
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Did/do you or any of the child's relatives have any of the following? (If YES, please identify relative)
*
Rows
Yes/No/DK
Family Member
Comments
ADHD
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Depression
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Anxiety or OCD
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Bipolar disorder/psychiatric problems
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Alcoholism, drug use/addiction
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Genetic (cystic fibrosis, hemophilia, Marfan syndrome, Leiden V mutation, neurofibromatosis etc.)
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Birth Defects
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Reaction to dyes or anesthesia
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Chemical exposure (military or job related)
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Immune problems, HIV or AIDS
Yes
No
Don't Know
Mother
Father
Sibling
Father's Parents
Mother's Parents
Other
Any additional medical problems that run in the family:
Home type:
*
House
Apartment
Mobile Home
Heating:
*
Forced Air
Hot Water/Radiator
Wood/Pellet Stove
Other
Drinking Water:
*
City
Well
Bottled
Fluoride in drinking water?
*
Yes
No
Unsure
Does your child spend time in a home built before 1970 or one recently remodeled?
*
Yes
No
Are there guns in the Home?
*
No
Yes (please explain below how they are stored)
Any Pets?
*
No
Yes (please list below)
Any cigarette smokers?
*
No
Yes (please list below)
Are you experiencing any family or financial problems?
*
No
Yes (please explain below)
Does your child have, or has he/she ever had:
*
Rows
Yes/No/DK
If Yes, please explain
Chickenpox (If Yes, please indicate When)
Yes
No
Don't Know
Frequent ear infections
Yes
No
Don't Know
Problems with ears or hearing
Yes
No
Don't Know
Nasal allergies
Yes
No
Don't Know
Problems with eyes or vision
Yes
No
Don't Know
Asthma, bronchitis, bronchiolitis, or pneumonia
Yes
No
Don't Know
Any heart problem or heart murmur
Yes
No
Don't Know
Anemia or bleeding problem
Yes
No
Don't Know
Blood transfusion
Yes
No
Don't Know
Frequent abdominal pain
Yes
No
Don't Know
Constipation requiring doctor's visits
Yes
No
Don't Know
Bladder/kidney infection
Yes
No
Don't Know
Bed-wetting (after 5 years old)
Yes
No
Don't Know
(For girls) Has she started her menstrual periods?
Yes
No
Don't Know
(For girls) Are there problems with her period?
Yes
No
Don't Know
Any chronic or recurrent skin problem (acne, eczema, etc.)
Yes
No
Don't Know
Frequent headaches
Yes
No
Don't Know
Convulsions or other neurological problem
Yes
No
Don't Know
Diabetes
Yes
No
Don't Know
Thyroid or other endocrine problem
Yes
No
Don't Know
Any other significant problem
Yes
No
Don't Know
Use of alcohol or drugs
Yes
No
Don't Know
Submit
Should be Empty: