Pediatric History Questionnaire Template - Medstar Georgetown University Hospital Page 3
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6Please list all medical diagnoses your child has:
Diagnosis
Age at time
Name of Physician who Diagnosed
of Diagnosis
Please list all medications your child takes:
Medication
Dosage
Route
Frequency
Physician
Start
Stop Date
(oral,nasal)
who
Date
prescribed
Does your child wear glasses or have problems seeing? ___________________ (
Please describe)
Results of last hearing evaluation: ___________
___
Date: ________________
Results of last vision evaluation: ____________
___
Date: ________________
Please list any special tests, procedures, and/or hospitalizations since birth (MRI, EEG):
Date
Procedure
Reason for Testing
Results of Procedure
Development
Please write the age when your child first performed the following skills (circle months or years)
Sat alone: __ __
(Months/Years)
Toilet-trained: ________ _
(Months/Years)
Crawled: ___
_ (Months/Years)
Learned to Write :___
_( Months/Years)
Walked: ___
_ (Months/Years)
Said a single word: __
_ (Months/Years)
Babbled: ___
_ (Months/Years)
Dressed Self :_
___( Months/Years)
Used a cup: __
__ (Months/Years)
Fed self: _________
__ (Months/Years)
Does your child use any of the following at home or at school?
Walker
Wheelchair
Special cups/spoons Pacifier Sippy cup
Assistive Technology Infant “walker” or jumper Infant Swing Exersaucer Bottle
Orthotics Helmet
Other: ______________________
Updated: 2/10/2014
File Location: Shared Drive Active Peds Forms/Questionnaire Forms/History Questionnaire
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