Initial Health Questionnaire

HOUSEHOLD

Please list all those living in the child's home

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:

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

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

Does anyone in your home smoke?

   

Do you have any pets at home?

What are your child care arrangements?

BIRTH HISTORY

 

Birth Weight                                       Was the patient born at term?                                 at                       weeks

Any problems during the pregnancy, labor or delivery?

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

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

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

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

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

GENERAL (DK = Don't Know)

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

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

Has your child had any surgeries?                                                  Explain Below

Has your child ever been hospitalized?                                                  Explain Below

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

Has your child ever seen any medical specialists?                                                  Explain Below

 

Is your child taking any medications?                                                  List

 

Any allergies to foods or medications?                                                List

 

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

Any previous reactions to immunizations?                                                   Explain Below

 

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 

Childhood Hearing Loss
Nasal Allergies/Hay Fever
Asthma
Tuberculosis
Heart Disease (before 55 years old)
High Cholesterol
Sudden/Unexplained Death
High Blood Pressure
Anemia
Bleeding Disorder
Dental Decay
Cancer (before 55 years old)
Thyroid Problems
Liver Disease
Kidney Disease
Diabetes (before 55 years old)
Obesity
Seizures or Epilepsy
Alcohol Abuse
Drug Abuse
Attention Deficit Hyperactivity Disorder
Depression/Anxiety
Other Mental Illness
Developmental Disability
Birth Defects
Immune Problems or HIV/AIDS
Thyroid Disease
Childhood Hip Problems

275 SE Cabot Dr., Suite B-102 

Oak Harbor, WA 98277

360-675-5555

© 2021 Pediatric Associates of Whidbey Island  

1690 Layton Rd.

Freeland, WA 98249

360-331-1314