Initial History Questionnaire

Initial History Questionnaire

Form Completed By *

Date Completed *

Date

Date(s) Updated

Date

Patient Name *

First Name Last Name

Birth Date *

Date

Age *

Sex *

M F

ID Number

Do you consider your child to be in good health? *

Yes No Don't know

Explain

Does your child have any special health care needs? *

Yes No Don't know

Explain

Has your child ever been hospitalized? *

Yes No Don't know

Explain

Is your child allergic to medicine or drugs? *

Yes No Don't know

Explain

Please list all those living in the child’s home. *

	Name	Relationship to Child	Birth Date/Age

Please list other siblings not living in the home.

	Name	Birth Date/Age	Where are they living?

Does the child live with both biological parents? *

Yes No

If no, what is the child’s current living situation?

Single-parent custody Joint custody Adoptive family Foster care Other

How often does the child have visitation with parent(s) not living in the home?

Birth weight *

Weeks pregnant at delivery *

Full-term Pre-term Post-term

How many weeks pre-term

How many weeks post-term

Delivery *

Vaginal Cesarean Reason

Any complications during birth or after birth? *

No Yes (Explain below)

Did the baby need to go to the NICU (neonatal intensive care unit)? *

No Yes (Explain below)

During pregnancy, did the mother *

	Yes	No	Unknown
Take prenatal vitamins?
Smoke or use e-cigarettes?
Drink alcohol?
Use marijuana?
Use illicit drugs?
Take other medications?

Blood Type of Mother *

Unknown Known

Baby *

Unknown Known

Mother's labs results *

	Positive	Negative	Unknown
Hepatitis B
HIV
Group B Streptococcus (GBS)

After birth, did the baby get *

	Yes	No	Unknown
Vitamin K shot?
Erythromycin eye ointment?
Hepatitis B shot?

How was the baby fed? *

Bottle formula Bottle breast milk Breastfed (Indicate how long below)

Did baby go home with biological mother from hospital after birth? *

Yes No (Explain below)

The recommendations in this questionnaire do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Original questionnaire included as part of the Bright Futures Tool and Resource Kit, 2nd Edition. The American Academy of Pediatrics (AAP) does not review or endorse any modifications made to this questionnaire and in no event shall the AAP be liable for any such changes. © 2019 American Academy of Pediatrics. All rights reserved.

American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org

Downloaded from http://publications.aap.org/books/chapter-pdf/1210341/bftk_initial_history_questionnaire.pdf by Physician's Computer Company user on 04 May 2022

	Don't Know	No	Yes	Details
Eye problems, cataracts, or retinoblastoma
Vision impairment or concerns
Nasal allergies (dust, pets, or environmental)
Frequent ear infections
Hearing loss or concerns
Multiple cavities or problems with teeth
Frequent colds or sore throats
Asthma, wheezing, or breathing problems
Bronchitis, bronchiolitis, or pneumonia
Heart murmur or other heart problems
High blood pressure
Frequent stomach pain
Constipation needing medical treatment
Food allergies or intolerance (eg, milk, gluten)
Feeding issues or underweight
Overweight or obesity
Urinary tract infections
Bed-wetting (after 5 years old)
Kidney, ureter, or bladder problems
Serious injuries or fractures
Bone, joint, or muscle problems
Frequent headaches or dizziness
Concussion or head injury
Convulsions, seizures, or neurological issues
Sleep problems or snoring
Skin rashes, eczema, or hives
Acne
Thyroid or other endocrine problems
Diabetes
Metabolic/genetic disorders
Anemia or bleeding problems
Cancer or chemotherapy
Bone marrow or organ transplant
Blood transfusion
HIV or AIDS
Chickenpox or zoster (shingles)
Developmental delays (speech or motor
School problems or learning difficulties
ADHD or behavioral concerns
Anxiety, depression, or mood problems
Tobacco, alcohol, or drug use
Exposure to family violence
Pregnancy or miscarriage
Sexually transmitted infections
Females: Issues with periods
Age of first period

	Surgery/Procedure	Date of Surgery/Child's Age	Where Completed	Details

	Don't Know	No	Yes	Who?	Details
Anemia or bleeding problems
Asthma
Allergies
Alcohol use problems
Bed-wetting (after age 10 years)
Cancer (before age 55 years)
Childhood hearing loss
Dental decay or multiple cavities
Depression or anxiety
Developmental disability
Diabetes
Heart attack (myocardial infarction)
Heart disease (before age 55 years)
High blood pressure
High cholesterol
HIV or AIDS
Kidney disease
Liver disease
Mental health conditions
Obesity
Seizures or epilepsy
Stroke
Substance abuse problems
Sudden death (before age 50 years)
Thyroid or endocrine disease
Tobacco use problems
Tuberculosis
Vision or eye problems

GENERAL

SOCIAL HISTORY

BIRTH HISTORY

Past Medical History

Surgical History

FAMILY HISTORY