Initial History Questionnaire
Form Completed By
Please list all hose living in the child's home
Are there siblings not listed above?
What is the child's living situation if not with both biological parents?
Lives with adoptive parents
Lives with foster family
If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?
Don't know birth history
Was your baby born at...
Were there any prenatal or neonatal complications
Was a NICU stay required?
During pregnancy, did mother use tobacco
During pregnancy, did mother drink alcohol
During pregnancy, did mother use drugs or medications
Used prenatal vitamins
If so, please list all:
Was the delivery:
If cesarean, why?
Was initial feeding...
How long breastfed?
Did your baby go home with mother from the hospital?
Do you consider your child to be in good health?
Does you child have any serious illnesses or medical conditions?
Has your child had any surgery?
Has your child ever been hospitalized?
Is your child allergic to medicine or drugs?
Do you feel your family has enough to eat?
Biological Family History: Have any family members had the following?
Childhood hearing loss
Heart disease (before 55 years old)
High cholesterol / takes cholesterol medication
Cancer (before 55 years old)
Diabetes (before 55 years old)
Bed-wetting (after 10 years old)
Epilepsy / Convulsions
Mental illness / Depression
Immune problems, HIV or AIDS
Additional family history
PAST HISTORY: Does your child have, or has your child ever had
Frequent ear infections
Problems with ears / hearing
Problems with eyes / vision
Asthma, bronchitis, bronchiolitis, or pneumonia
Any heart problem or heart murmur
Anemia or bleeding problem
Malignancy / Bone marrow transplant
Frequent abdominal pain
Constipation requiring doctor visits
Recurrent urinary tract infections and problems
Congenital cataracts / retinoblastoma
Metabolic / Genetic disorders
Kidney disease / Urologic malformations
Bed-wetting (after 5 years old)
Sleep problems: snoring
Chronic / recurrent skin problems (ex. acne, eczema)
Convulsions or other neurologic problems
Thyroid or other endocrine problems
High blood pressure
History of serious injuries / fractures / concussions
Use of alcohol / drugs
ADHD / anxiety / mood problems / depression
History of family violence
Sexually transmitted infections
(For girls) Problems with her periods
(For girls) Has had first period
Any other significant problems
Age of first period
Should be Empty: