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Pediatric Health Questionnaire
Patient's Name
Today’s Date
Age
Date of Birth
Sex
Home Phone
Mother’s Name
Cell
Father’s Name
Cell
Home Address
City
State
Zip
Work Phone
Parent's Email
Name & Address of Dr’s Office/Hospital/Clinic where your child’s health records are kept:
Reason for referral or presenting problem
MEDICATIONS:
Aspirin
Now
Past
Tylenol
Now
Past
Decongestant
Now
Past
Ibuprofen
Now
Past
Antibiotics
Now
Past
Anti‐Histamine
Now
Past
Other
Allergic to Medicines
MEDICAL HISTORY:
Childhood Illnesses:
Chicken Pox
Yes
No
Scarlet Fever
Yes
No
Tonsillitis
Yes
No
# of Times
Measles
Yes
No
Pneumonia
Yes
No
Ear Infections
Yes
No
# of Times
Mumps
Yes
No
Frequent Colds
Yes
No
Rubella
Yes
No
Rheumatic Fever
Yes
No
Other ‐ Please Specify
Has your child had any of the following tests? - WHERE, WHEN, RESULTS
Electroencephalogram
Psychological Evaluation
Hearing Test
Speech/Language Testing
Injuries/Surgeries/Hospitalizations (please list)
IMMUNIZATIONS:
Measles
Yes
No
Polio
Yes
No
MMR
Yes
No
Smallpox
Yes
No
Diphtheria
Yes
No
Mumps
Yes
No
DPT
Yes
No
Tetanus
Yes
No
Influenza
Yes
No
Pneumonia
Yes
No
COVID
Yes
No
Other (List)
DIET:
Please describe your child’s typical daily diet:
BIRTH HISTORY:
Term:
Pneumonia
Full
Premature
Late
Weight at birth (lbs, oz)
Length of Labor
Complications?
Has your child has any of the following problems?
Jaundice
Diarrhea
Birth Defects
Rashes
Colic
Fever
Allergies
Cerebral Palsy
Blue Baby
Seizures
Birth Injuries
Other (Explain)
Child’s sleep pattern (first year)
Food Intolerances (if any)
Feeding:
Breast fed?
How Long?
Formula?
Milk or Soy
Age Began:
Solid Foods
Sitting
Crawling
Walking
First Words
SYMPTOMS: (Mark 1 for Current Symptoms and 2 for Past Symptoms)
Hives
Burning of urine
Bloody urine
Frequent Urination
Eczema
Cries Easily
Heart Murmur
Nervous
Nose Bleeds
Vomiting Spells
Stomach Aches
Acne
Anemia
Night Sweats
High Fever
Jaundice
Sensitive to Light
Chronic Rash
Sleep Problems
Hearing Loss
Body/Breath Odor
Easy Bruising
Motion/Car Sickness
Diarrhea
Flat Feet
No Appetite
Sore Throat
Constipation
Nightmares
Frequent Headaches
Frequent Colds
Gas
Canker Sores
Bleeding Tendency
Unusual Fears
Wheezing
Joint Pain
Excessive Fatigue
Cough
Dizzy Spells
Hair Loss
Other (Explain)
FAMILY HISTORY:
Heart Disease
Diabetes
Birth Defects
Hypertension
Arthritis
Tuberculosis
Cancer
Allergies
Mental Illness
Previous pregnancies by natural mother, miscarriages or complications?
Mother’s age at child’s birth
Mother’s health during pregnancy?
Bleeding
Nausea
Hypertension
Diabetes
Illnesses
Medications
Thyroid Problems
Physical or emotional trauma
Cigarettes, alcohol, drug consumption
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