Download CHILDGROVE PEDIATRICS

CHILDGROVE PEDIATRICS
New Patient Questionnaire
Today’s Date: ________________________________
Patient name: _____________________________
Date of Birth: _____________________________
Mother’s name: ____________________________
Father’s name: _____________________________
Pregnancy and Birth
1.
Mother’s age at birth
2.
Did mother have any illness
during pregnancy?
3.
Did mother take any medication
other than vitamins and iron?
4.
Was baby born earlier than
due date?
At how many weeks?
5.
What was the birth weight?
6.
Did the baby have any trouble
while in the hospital?
What kind?
___________
No
Yes
No
Yes
No
Yes
___________
_____________
No
Yes
_____________
Past Medical History
1.
Has your child had allergic
reactions to any medication,
foods, or insect bites?
No
Yes
2.
Has your child had reactions to any
immunizations?
No
Yes
3.
Any hospitalizations
other than birth?
No
Yes
4.
Any serious injuries?
No
Yes
5.
Any surgeries?
No
Yes
6.
Are any medications
taken regularly?
No
Yes
7.
Date of last check up
_____________
8.
Date of last dental check-up
_____________
If yes to any of the above questions please explain:
_____________________________________________
_____________________________________________
_____________________________________________
Family History
1.
Are child’s parents
in good health?
Yes
No
2.
Circle any diseases that this child’s parents,
grandparents, brothers, sisters, or aunts and uncles
have had: asthma, allergies, cancer, diabetes, high
blood pressure, high cholesterol, heart trouble,
tuberculosis, inherited diseases or sudden death.
3.
Have any of your children died? No
Yes
Social History
1.
List age gender, and general health condition of
brothers and sisters:
________________________________________
________________________________________
2.
List household members:
________________________________________
________________________________________
3.
List any type of household pets:
________________________________________
4.
Are there any smokers
in the house?
No
Yes
5.
Does this child
attend daycare?
No
Yes
Feeding and Nutrition
1.
Is your child’s appetite
generally good?
Yes
No
2.
Were there severe colic or any unusual feeding
problems in the first 3 months? No
Yes
3.
During the first 12 months was your child breast
fed, bottle fed or both?(circle one)
Review of systems
1.
Has your child had
frequent ear infections?
No
Yes
2.
Any eye problems?
No
Yes
3.
Has he/she had any
problems with teeth?
No
Yes
4.
Does he/she have frequent colds
or sore throats?
No
Yes
5.
Does he/she have asthma,
recurring cough or pneumonia? No
Yes
6.
Does he/she have a heart murmur
or any heart trouble?
No
Yes
7.
Any problems with urination? No
Yes
8.
Any problems with diarrhea
or constipation?
No
Yes
9.
Have there been any convulsions
or seizures?
No
Yes
10. Any eczema, hives, or
other skin condition?
No
Yes
11. Has your child ever
been anemic?
No
Yes
Safety
1.
Do you live in a private house, apartment, mobile
home or other? (circle one)
2.
Do you know the temperature of your hot water
heater?
Yes
No
3.
Is there a working smoke alarm on each floor of
your house?
Yes
No
4.
Does your child always use a car seat/seat belt
when riding in the car ?
Yes
No
5.
Does your child always wear appropriate
protective equipment when riding bike, skate
boarding or roller-blading?
Yes
No