Pediatric History Questionnaire
Form Completed By
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Date Completed
*
/
Month
/
Day
Year
Date
Patient Name
*
Patient Birth Date
*
/
Month
/
Day
Year
Date
Birth Gender:
*
Male
Female
Age
GENERAL
Rows
Yes
No
Don't Know
Explain
Do you consider your child to be in good health?
Does your child have any special health care needs?
Has your child ever been hospitalized?
Is your child allergic to medicine or drugs?
SOCIAL HISTORY
Please list all those living in the child's home.
Rows
Name
Relationship to Child
Birth Date/Age
Row 1
Row 2
Row 3
Row 4
Row 5
Row 6
Row 7
Please list other siblings not living in the home.
Rows
Name
Birth Date/Age
Where are they living?
Row 1
Row 2
Row 3
Row 4
Row 5
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 Family Members
How often does the child have visitation with parent(s) not living in the home?
*
BIRTH HISTORY
Birth Weight
Type a question
*
Full-term
Preterm
Post-Term
Preterm Weeks
*
Post-Term Weeks
*
Delivery
Vaginal
Cesarean
Any complications during birth or after birth?
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No
Yes
Explain
*
Did the baby need to go to the NICU (neonatal intensive care unit)?
*
No
Yes
Explain
*
During pregnancy, did the mother:
Rows
Yes
No
Unknown
Take prenatal vitamins?
Smoke or use e-cigarettes?
Drink alcohol?
Use marijuana?
Use illicit drugs?
Take other medications?
If took other medications, please list
Blood Type
Rows
Blood Type
Unknown
Mother
Baby
Mother's lab results
Rows
Postive
Negative
Unknown
Hepatitis B
HIV
Group B Streptococcus (GBS)
After birth, did the baby get:
Rows
Yes
No
Unknown
Vitamin K shot?
Erythromycin eye ointment?
Hepatitis B shot?
How was the baby fed?
Bottle formula
Bottle breast milk
Breastfed
How long was baby breastfed?
Did baby go home with biological mother from hospital after birth?
Yes
No
Explain why baby did not go home with biological mother.
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PAST MEDICAL HISTORY
Has your child ever had any of the following problems? DK=Don't Know
Condition
Rows
DK
No
Yes
Details
Eye problems, cataracts, or retinoblasoma
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 yrs 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 swings
Tobacco, alcohol, or drug use
Exposure to family violence
Pregnancy or miscarriage
Sexually transmitted infections
Females: issues with periods
Females: age of first period
Other medical problems (please list)
SURGICAL HISTORY
Has your child ever had surgery? If yes, please provide details below
Yes
No
Surgical History
Rows
Surgery/Procedure
Date of Surgery/Childs Age
Where Completed
Details
Row 1
Row 2
Row 3
Row 4
Row 5
Row 6
Other surgical/procedural problems (please list)
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FAMILY HISTORY
Have any of your child's parents, grandparents, aunts, uncles, brothers, or sisters ever had any of the following conditions? DK=Don't Know
Condition
Rows
DK
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 use problems
Sudden death (before age 50 years)
Thyroid or other endocrine disease
Tobacco use problems
Tuberculosis
Vision or eye problems
Other medical problems
Patient/Guardian
*
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SIGNATURE
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