All Children Pediatrics HEALTH QUESTIONNAIRE
Instructions: Please fill out additional forms for each child ONLY ONE(1) Social and Family History needs to be completed
Patient Name
DOB
Medications: List all current medications and strengths your child is on:
DRUG ALLERGIES: List all
ALLERGIES
Allergic Rhinitis
Eczema/chronic dry skin
Asthma
Food intolerance
Urticaria (hives)
Birthweight
NEWBORN PERIOD
Vaginal delivery
C Section
Difficult Delivery
Term
Premature
Jaundice
Phototherapy
Heart or lung problems
Feeding problems
Delayed discharge home from nursery
Other
FEEDING & DIGESTION
Breastfed
Bottle-fed
Appetite poor
Constipation issues
Chronic loose stools
Vomiting
Other
INFECTIONS, DEVELOPMENT, MISCELLANEOUS PROBLEMS:
Dental problems
Developmental delays
Eye problems (glasses, etc)
Frequent sore throats
Frequent ear infections
Hearing loss
Heart problems
Elevated blood pressure
Seizures
Pneumonia
Pica (eating dirt,plants, etc. )
Orthopedic Problems
Kidney or bladder infections
Bed wetting
Other
SURGICAL PROCEDURES
Tonsillectomy, adenoidectomy and/or ear tubes
Serious injuries (concussion, broken bones, etc.)
Other surgical procedures
Other
HOSPITALIZATIONS
PSYCHOLOGICAL PROBLEMS
Antisocial behavior
ADHD issues
Drug use/abuse
Discipline problems
Breath-holding
Anxiety
Peer relationships
Tics/ nervous habits
Learning disability
Mental retardation
Nightmares
Temper tantrums
Speech problems
Poor school performance
School adjustment problems
Other
Mother and Age
Father and Age
Email address
example@example.com
List all Children and DOB (Dates of Birth)
1.
2.
3.
4.
5.
6.
FAMILY SOCIAL HISTORY (SH)
Parent's marital status
Married
Single
Divorced
If divorced, who has custody?
What are your living arrangements?
House
Apartment
Rent
Own
House or apartment age?
How many adults live in the household?
How many children live in the household?
Parents Employed
Mother: Yes
Mother: No
Father: Yes
Father: No
Mother Employed By Whom?
Father Employed By Whom?
Family History: Paternal (Father's) Side
Unknown/ No Information
No inheritable medical problems
Alcoholism/ drug use
Allergies
Asthma
Bleeding disorders
Cancer
Cerebrovascular disease (stroke)
Crohn's disease
Depression
Diabetes
Eczema
Early heart attacks (< age 50)
Hearing loss
Heart disease
Heartburn (GERD)
High Cholesterol
High Blood Pressure
Hyperthyroid (over-active thyroid)
Hypothyroid (under-active thyroid)
Iron deficiency/anemia
Kidney disease
Lupus
Mental illness (other than depression)
Rheumatoid arthritis
Seizures
Tuberculosis
Ulcerative colitis
Family History: Maternal (Mother's) Side
Unknown/ No Information
No inheritable medical problems
Alcoholism/ drug use
Allergies
Asthma
Bleeding disorders
Cancer
Cerebrovascular disease (stroke)
Crohn's disease
Depression
Diabetes
Eczema
Early heart attacks (< age 50)
Hearing loss
Heart disease
Heartburn (GERD)
High Cholesterol
High Blood Pressure
Hyperthyroid (over-active thyroid)
Hypothyroid (under-active thyroid)
Iron deficiency / anemia
Kidney disease
Lupus
Mental illness (other than depression)
Rheumatoid arthritis
Seizures
Tuberculosis
Ulcerative colitis
List any other inherited health issues or serious health problems present in either side of the family not covered on the list above
Submit
Should be Empty: