PEDIATRIC PATIENT QUESTIONNAIRE
atient's Name: ___________________________________ Date of Birth: _____________________
Informant: _______________________________ Relationship: ______________________
Circle Y, N or write NA, if yes, specify
MOTHER’S PREGNANCY/CHILD’S BIRTH HISTORY:
Illnesses during pregnancy? N Y
Any medications during pregnancy? N, Y
Smoking/Alcohol/Drug Abuse? N, Y
Problems/complications at birth? N, Y
Type of delivery? Vaginal_____ C-section_____ If C-section, reason ______________
Was the baby in time, early or late______________________ Specify __________________
Birth Weight______________
Did baby receive Hepatitis B vaccine? Y, N
Date of Hepatitis B immunization______________
Name of Hospital
Complications after birth __________________________________________________________
Hearing screening at birth: Normal, abnormal
Was PKU test done? N Y
PAST MEDICAL HISTORY: Has your child ever had:
Measles/Mumps/Chicken Pox? N Y
Frequent ear infections? N Y
Vision/Hearing Problems? N Y
Skin Problems? N Y
Asthma/Allergies? N Y
PLEASE SPECIFY ALLERGIES _________________________________________________________
TB/Lung Disease/Croup? N Y
Seizures/Epilepsy? N Y
High Blood Pressure? N Y
Heart Defects/Disease? N Y
Liver Disease/Hepatitis? N Y
Diabetes? N Y
Kidney Disease/Bladder Infections? N Y
Handicaps/Disabilities? N Y
Bleeding Disorders/Hemophilia? N Y
Sexually Transmitted Diseases? N Y
Emotional Problems/Suicide Attempts? N Y
Hospitalizations/Surgeries? N Y
Physical/Emotional Abuse/Broken bones? N, Y
FEEDING AND NUTRITION
Food allergies: Yes, No, specify__________________________________________________________
Appetite usually good” Yes, no, ________________________________________________________
Breast fed yes, no ______________ For how many months? ____________
Bottle fed _______________________ What Milk (Formula)____________________________________
Feeding problem/colic in the first 3 months__________________________________________
Special diet _____________________________Vitamins____________ Fluoride ______________
Family History: Has anyone in the family (parents, grandparents, uncles, aunts, cousins)
Suicide Attempts? N Y
Heart Disease? N Y
High Blood Pressure? N Y
High Cholesterol? N Y
Blood Disorders? N Y
Diabetes? N Y
Seizures? N Y
Allergies/Asthma? N Y
Mental Illness? N Y
Mental Retardation? N Y
Cancer? N Y
Birth Defects? N Y
Hearing Speech Problems? N Y
Kidney Disease? N Y
HIV/AIDS? N Y
SOCIAL HISTORY
How many living in the household?
Who cares for child?
Who lives in household?
Grade?
Report Card?
School behavior problems Yes, No, specify _________________________________________
ANY OTHER ISSUES