New Patient Questionaire


Now

A. PREGNANCY AND BIRTH:

Did the mother have any illness during pregnancy?:

Did she take any other medications other than vitamins and iron?:

Was the baby on time?:

Did the baby have any trouble starting to breathe?:

Did the baby have any trouble while in the hospital? (jaundice, infections, other?):

B. PAST MEDICAL HISTORY:

Has your child had allergic reactions to any medications, foods, insect bites?:

Has your child had reactions to any immunizations?:

Any hospitalizations other than for birth?:

Any serious injuries?:

Are any medications taken regularly?:

Has your child ever had chicken pox?:

Has your child ever had any known exposure to tuberculosis?:

C. FAMILY HISTORY:

Are the child’s parents both in good health?:

Choose any diseases that this child’s parents, grandparents, brothers, sisters, or aunt and uncles have had:














Have any of your children died?:

D. FEEDING AND NUTRITION:

Is your child’s appetite usually good?:

Is it good now?:

Was there severe colic or any unusual feeding problem during the first 3 months?:

Do any foods disagree with him/her?:

Does he/she take vitamins?:

E. REVIEW OF SYSTEMS:

Has your child had frequent ear infections?:

Any eye problems?:

Has he/she had any problems with teeth?:

Does he/she have frequent colds or sore throats?:

Is there asthma, pneumonia, or recurrent cough?:

Does he/she have a heart murmur or any heart problems?:

Any problems with urination?:

Any problems with diarrhea or constipation?:

Have there been any convulsions, or other problems with the nervous system?:

Any eczema, hives, or other skin conditions?:

Has your child ever been anemic?:

F. DEVELOPMENT/BEHAVIOR:

Did he/she say any words by the time he/she was 1 1/2 years old?:

Does he/she have any trouble sleeping?:

Has he/she had trouble in school?:

Does he/she get along with other children?:

Choose if your child has had any of the following:









G. SAFETY/ENVIRONMENT:

Do you live in a:



Do you know the hottest temperature of the water in your pipes?:

Is there a working smoke alarm on each floor in the house?:

Does your child always use a car seat/seat belt when riding in a car?:

Are there any smokers in the household?:

Are there any problems with the condition of your home? (peeling paint, insects, rats or mice):

Does your child always wear a helmet when riding his/her bicycle?:

Are there any guns in the household?:

H. DO YOU HAVE A RECORD OF IMMUNIZATION?: