Patient Medical History Questionnaire Form Page 2
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2Patient Medical History Questionnaire
Today’s Date:_________
REVIEW OF SYSTEMS
Has your child had frequent ear infections?
No/Yes
Any hearing problems?
No/Yes
PAGE 2
Any vision problems?
No/Yes
Has he/she had any problems with teeth?
No/Yes
Does this child have frequent colds or sore throat?
No/Yes
Does he/she have a history of allergies, asthma
Pneumonia, bronchitis or recurrent cough?
No/Yes
FEEDING AND NUTRITION
(circle any which are yes)
Current nutrition: breast fed, formula fed, table food (circle)
Any problems with kidneys, bladder or urination?
No/Yes
For the first 6 moths was this child breast fed or formula fed:
Have there been any convulsions or any other
(circle) If formula fed, which one?____________________
problems with the nervous system?
No/Yes
Amount _________oz per ___________________________
Any problems with diarrhea or constipation?
No/Yes
If on regular milk, which? Whole, 2% 1%, non fat? (circle)
Any eczema, hives or other skin conditions?
No/Yes
Amount of milk per day? ____________________________
Has your child ever been anemic?
No/Yes
Is your child’s appetite usually good?
No/Yes
Has your child ever seen a specialist?
No/Yes
Is it good now?
No/Yes
If so, for what?________________________________
Was there severe colic or any other unusual feeding problems
Please note any other important facts:
during the first three months?
No/Yes
______________________________________________
Do any foods disagree with him/her?
No/Yes
If so, which ones?_______________________________
Does he/she take vitamins/fluoride?
No/Yes
Which ones?___________________________________
SAFETY/ENVIRONMENT
Do you live in a private house, mobile home,
apartment, condo, other?________________________
Who currently lives in the household?
DEVELOPMENT/BEHAVIOR
_____________________________________________
(Answer if child is less than 5 years –ONLY)
Do you know the hottest temperature of the water in your
At what age did this child sit alone?___________________
pipes?
No/Yes
At what age did he/she walk alone?____________________
Is there a working smoke alarm for each floor of your house?
Did he/she say any words by 15 months of age?
No/Yes
No/Yes
How does this child compare to others of his/her age?
Is there a working fire extinguisher in your home?
No/Yes
Same, Advanced, Behind (circle one)
Does the child always use a car seat/seat belt while in the car?
Are there any problems with sleeping?
No/Yes
No/Yes
Are there any smokers in the home?
No/Yes
(Answer if child is more than 5 years—Only)
Are there any problems with the condition of your home?
What grade is the child? ______________________________
(Peeling paint, insects, rats or mice?)
No/Yes
Has he/she had any trouble with school?
No/Yes
Does your child always wear a helmet when riding a
Does she/he get alone well with other children?
No/Yes
bicycle/skateboard or other like activities?
No/Yes
If your child has had any of the following, please circle:
Are there pets in your home?
No/Yes
Nail biting, thumb sucking, bed wetting, bad temper, problems
If yes, how many and what types?__________________
with toilet training, hyperactivity, nightmares, speech
_____________________________________________
problems, problems with discipline,
Are there guns in the home?
No/Yes
others:____________________________________________
Is there a swimming pool or hot tub?
No/Yes
__________________________________________________
PediatricQuestionnairePage1and210132010.doc
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