Initital History Questionnaire Form - Yale Health - Pediatric Department
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2If possible attach a copy of your child’s immunization
Yale Health – Pediatric Department
record and return with this form at your appointment.
Initial History Questionnaire
Child’s Name
Date of Birth
Age
Address
Form Completed By
Date Completed
Home Phone
Cell Phone
Work Phone
Household - please list all those living in the child’s home
Are there siblings not listed? If so,
please list their names and ages and
Relationship
Name
to child
Age
Occupation
Health Problems
where they live.
_____________________
_____________________
If parents are not living together or if
child does not live with parents, what
is the child’s custody status?
Birth History
Birth weight ______lbs. _______oz.
Date of adoption (if applicable)____________
Was the baby born at term?____ Early? ____Late?____
Was the delivery □ Vaginal? □ Cesarean?
If early, how many weeks gestation?_________
If cesarean, why? ______________________________
Did mother have any illness or problem with her pregnancy?
_____________________________________________
□ Yes
□ No Explain _______________________________
Did baby have any problems right after birth?□ Yes □ No
___________________________________________________
Explain_______________________________________
During pregnancy did mother: Smoke? □ Yes □ No
_____________________________________
Drink alcohol? □ Yes □ No
Was initial feeding □ Breast? □ Bottle?
Use drugs or medications? □ Yes □ No What? And When?
Did baby go home with mother from the hospital?
___________________________________________________
□ Yes □ No
Explain____________________________
General (if applicable)
Do you consider your child to be in good health?
□ Yes □ No Explain______________________________
Does your child have any serious illness or medical condition?
□ Yes □ No Explain______________________________
Has your child had serious injuries or accidents?
□ Yes □ No Explain______________________________
Has your child had any surgery?
□ Yes □ No Explain______________________________
Has your child been hospitalized?
□ Yes □ No Explain______________________________
Is your child allergic to any medicine or drugs?
□ Yes □ No Explain______________________________
Does your child take any medications on a regular basis?
□ Yes □ No Explain______________________________
Development (if applicable)
Name of school (or daycare) and grade in school____________________________________________________________
How is his/her behavior in school? _______________________________________________________________________
Has he/she repeated a grade in school? ___________________________________________________________________
How is he/she doing in academic subjects? ________________________________________________________________
Is he/she in special or resource classes? ___________________________________________________________________
Are you concerned about your child’s physical development?
□ Yes □ No Explain______________________________
Are you concerned about your child’s mental or emotional
□ Yes □ No Explain______________________________
development?
Are you concerned about your child’s attention span?
□ Yes □ No Explain______________________________
Clinician Signature_____________________________________________
OVER---
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