Initial History Questionnaire - Federal Way Pediatric Associates

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Federal Way Pediatric Associates
32124 1st Ave S. Suite 100
Federal Way, WA 98003
Ph (253) 661-5939 Fax (253) 661-5929
Mohinder Badyal, MD
INITIAL HISTORY QUESTIONNAIRE
Form completed by_______________________________________ Relation to child ___________________________ Date completed_________________
Child’s Name____________________________________________ Date of birth__________________________ SS#________________________________
Parent’s name_______________________________________________
Address_________________________________________________________________________________________________Phone___________________
Emergency contact__________________________________________________________Phone_________________________
Family History
Mother________________________ Age_______ Health problems__________________________________________________________________________
Father_________________________ Age_______ Health problems__________________________________________________________________________
Sibling_________________________ Age________ Sex_____ Health problems_________________________________________________________________
Sibling_________________________ Age________ Sex_____ Health problems__________________________________________________________________
Sibling_________________________ Age________ Sex_____ Health problems__________________________________________________________________
Sibling_________________________ Age________ Sex_____ Health problems__________________________________________________________________
Sibling_________________________ Age________ Sex_____ Health problems__________________________________________________________________
Birth History
Birth weight_____________ Was the delivery:  vaginal?
Was the baby born  Term?  Early? (
 c-section? yes, because_______________________________________________________
weeks gestation)  Late?
Did mother have any illness or problem with her pregnancy?  No
During pregnancy, did the mother smoke? Yes No
 Yes, because _____________________________________________________________
Drink alcohol?  Yes  No
Use drugs or medications?  Yes  No
Did your baby have any problems right after birth?  No  Yes, because______________________________________________________________________
General
Do you consider your child to be in good health?  Yes  No, because_______________________________________________________________________
Does your child have any serious illness or medical condition? _________________________________________________________________________________
Has your child had serious injuries or accidents? ____________________________________________________________________________________________
Has your child had any surgery? _________________________________________________________________________________________________________
Has your child ever been hospitalized? ____________________________________________________________________________________________________
Is your child allergic to any medications or drugs? ___________________________________________________________________________________________
Development
Are you concerned about your child’s physical development? _________________________________________________________________________________
Are you concerned about your child’s mental or emotional development? _______________________________________________________________________
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