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 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