Initial Health Questionnaire

HOUSEHOLD

Please list all those living in the child's home

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Name                                                           Relationship to Child                                   Age (children) or Occupation (adults)

Are there siblings not listed? If so, please list their names, ages and where they live:

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What is the child's living situation if not with both biologic parents?

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If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?

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Does anyone in your home smoke?

Do you have any pets at home?

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What are your child care arrangements?

BIRTH HISTORY

Birth Weight                                       Was the patient born at term?                                 at                       weeks

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Any problems during the pregnancy, labor or delivery?

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Did your baby have any medical problems in the hospital as a newborn?

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Did your baby stay in the hospital longer than the mother?

FEEDING (Complete if your child is 2 years old or less)

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Is (or was) your baby fed by                                                                          Type of formula?

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Is your child still breast fed?                                           Is your child still taking a bottle?

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GENERAL (DK = Don't Know)

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Do you consider your child to be in good health?                                                  Explain Below 

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Does your child have any serious illnesses or medical conditions now or in the past ( i.e. asthma, allergies, seizures, urinary tract infections, ear infections, anemia)?                                                   Explain Below

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Has your child had any surgeries?                                                  Explain Below

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Has your child ever been hospitalized?                                                  Explain Below

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Have there ever been any serious accidents, broken bones, or concussions?                                              Explain Below

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Has your child ever seen any medical specialists?                                                  Explain Below

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Is your child taking any medications?                                                  List

Any allergies to foods or medications?                                                List

Are your child's immunizations up to date?                                                  Explain Below

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Any previous reactions to immunizations?                                                   Explain Below

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Have you been concerned with your child's development or school performance or is your child getting special help in school?                                                             Explain Below

BIOLOGIC FAMILY HISTORY 

Thanks for submitting!