Pediatric History Questionnaire Template - Medstar Georgetown University Hospital Page 2
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6Family Medical History
Biological Child Adoption Foster care Surrogacy
Age at adoption/foster care placement: _________
Additional information: _______________________________________________
____
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Pregnancy
Complications: ________
__________ ________________________________
___________________________________________________
_____________
Medications taken during pregnancy: ________________________________
Prenatal exposure to alcohol tobacco drugs other: ______________
Maternal hospitalizations: because of ________________________________
From ______ weeks gestation to ______ weeks gestation
Breech Position
Other: _________________________________________________________
Birth
Name of Hospital: ______________________ Length of Stay: ______________
Born at ______ weeks gestational age.
Vaginal birth Difficult Labor_____________ Other: _________________
C-section reason: ______________________________________________
Birth Weight: __________________ Apgar Scores: _____________________
Complications: __________________________________________________
Neonatal
NICU stay Hospital: ______________________ Length of Stay: __________
Ventilator/Breathing Tube
Difficulty Feeding
Oxygen tube
Physical/Occupational Therapy
Retinopathy of Prematurity
Speech Therapy
Seizures
Intraventricular Hemorrhage (IVH) Grade_____
Reflux/Gastroesophageal Reflux Disease (GERD)
Periventricular Leukomalacia (PVL)
Additional Diagnoses:
Hearing Screening
Results: Pass Fail
Vision Screening
Results: Pass Fail
Current Medical Status
Please tell us all other doctors or specialists involved in your child’s care:
Specialty of Physician
Name of Physician
Date Last Seen
Phone
Fax Number
(ENT, GI, Geneticist)
(First and Last)
Number(s)
Pediatrician
Updated: 2/10/2014
File Location: Shared Drive Active Peds Forms/Questionnaire Forms/History Questionnaire
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