Infant Pediatric Health History Form - Initial Visit Questionnaire
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1ABC Pediatrics, Ltd.
Infant Pediatric Health History Form—Initial Visit
Child’s Name ______________________Age _____
Child’s DOB ____________ Today’s date _______
Your Name _________________________________
Relationship to Child ________________________
Pregnancy and Birth
Feeding and Nutrition
Any unusual feeding problems?
_ No
_ Yes
Maternal Exposures:
Breast or formula fed? _______________________________
Medication?
_ No _ Yes
_______________
If on formula, which one? ____________________________
Drugs/Alcohol?
_ No _ Yes
_______________
Does he/she take vitamins? ___________________________
Tobacco?
_ No _ Yes
_______________
If breastfeeding, how long do you plan to continue? ________
Infection/Grp B strep?
_ No _ Yes
_______________
Review of systems
Birth problems for patient:
Any eye problems?
_ No
_ Yes
Jaundice?
_ No _ Yes
_______________
Difficult or noisy breathing?
_ No
_ Yes
Infection?
_ No _ Yes
_______________
Heart murmur or heart problem?
_ No
_ Yes
Breathing?
_ No _ Yes
_______________
Problem with stools (diarrhea/constipation)? _ No
_ Yes
Low Blood Sugar?
_ No _ Yes
_______________
Is he/she irritable or colicky?
_ No
_ Yes
Oxygen Use?
_ No _ Yes
_______________
Any skin conditions?
_ No
_ Yes
NICU stay?
_ No _ Yes
_______________
Problem with vomiting or excessive spit up? _ No
_ Yes
Please list any other medical problems or explain above
Was your child premature? _ No _ Yes, born at ____weeks
problems. _________________________________________
Delivery: _vaginal _c-section _breech _forceps
__________________________________________________
Where was your child born? _________________________
Is the child yours by _birth _adoption _ stepchild _other
Social History
Birth weight ________________
Length ______________
Who lives in the child’s household? _Mom _Dad _Step ___
Mother’s blood type?________________________________
_ Siblings (# ___) _Grandparents _Other ________
Other problems in the newborn period __________________
Child’s parents are _married _unmarried _ divorced _other
_________________________________________________
Mom’s Occupation __________Dad’s Occupation_________
Childcare _parents _relatives _daycare _babysitter/nanny
Past Medical History of Your Infant
Days per week in childcare (not with parent) ______
Any medications taken regularly?
_ No _ Yes
Any pets? _ Yes _ No ______________________________
Which ones?________________ ______________________
Do any household members smoke? _ Yes _ No
Any allergic reactions to medications?
_ No _ Yes
Which ones?_______________________________________
Family History
Any reactions to immunizations?
_ No _ Yes
Do any family members have any of the following conditions:
Which ones? _______________________________________
Condition
Mother Father
Sibling Grandparent
Any hospitalizations other than for birth?
_ No _ Yes
Asthma
_
_
_
_
For what? _________________________________________
Allergies
_
_
_
_
Other history?
_ No _ Yes
Anemia
_
_
_
_
Which kind?_______________________________________
Blood disorder
_
_
_
_
__________________________________________________
Cancer
_
_
_
_
Diabetes
_
_
_
_
High cholesterol
_
_
_
_
Safety / Environment
High blood pressure_
_
_
_
Is your water heater set to 120 degrees?
_ Yes
_ No
Heart attack/disease_
_
_
_
Is there a working smoke alarm on each
Thyroid Disease
_
_
_
_
floor in the house?
_ Yes
_ No
Kidney disease
_
_
_
_
Does your child always use a car seat
Seizures
_
_
_
_
in the back seat when riding in the car?
_ Yes
_ No
Migraines
_
_
_
_
Do you place your baby to sleep on
Autism
_
_
_
_
his/her stomach?
_ No
_ Yes
Depression/anxiety _
_
_
_
Do you have help or support easily
Alcoholism
_
_
_
_
available?
_ Yes
_ No
ADD/ADHD
_
_
_
_
Any stresses in the family?
_ No
_ Yes
Other issues
_
_
_
_
Describe _________________________________________
_____________
_
_
_
_
_________________________________________________
Please explain all positives.___________________________
_________________________________________________
__________________________________________________
Where does the baby sleep: _____parents’ room, ____nursery
Comments
______sibling’s room, ______other?
________________________________________________
________________________________________________
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