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? _______________________________________________________________________