New Patient Questionnaire

 

Patient Name:  DOB:  Chart #: 

Person Filling Out This Form?  Other:

Mother's Name Age:
Father's Name Age:
Legal Guardian's Name Age:

If adults in the household work outside the home, what childcare arrangements are made for this child?
 

A. PREGNANCY AND BIRTH: (Please choose from the dropdown. If YES, please explain in the lines provided to the right.)

1) Mother's age at patient's birth:  
2) Did mother have any illnesses during pregnancy?
3) Did she take any medications other than vitamins & iron?
4) Alcohol?
5) Cigarette use? 
6) Marijuana / Drugs?
7) History of herpes, HIV, or other genital infections? 
8) What was your due date? 
9) Vaginal or cesarean?
10) If cesarean, why?  
11) What was the birth weight?
12) Did the baby have any trouble starting to breathe?
13) Did the baby have any trouble while in the hospital? (jaundice, infections, surgeries, other?) 
 

B. PAST MEDICAL HISTORY

1) Any serious past medical problems?
2) Any past surgery (including ear tubes)?
3) Date of last physical checkup:
4) Date of last dental checkup:
5) Has your child had allergic reactions to any medications, foods, insect bites?
6) Has your child had reactions to any immunizations?
7) Any hospitalizations other than for birth?
8) Any serious injuries?
9) Take medications regularly?
10) Alternative medicine / herbal remedies?
 

C. FAMILY HISTORY:

 
1) Are the child’s parents both in good health?

2) Please indicate if mother (M), father (F), siblings (S), grandparent (GF, GM, etc.) have had any of the following & explain in the space below: 
 
Arthritis Allergy (Type)
High Cholesterol    
High Blood Pressure Inherited/Genetic
Stroke Cystic Fibrosis
Diabetes Sickle Cell
Kidney Disease Hemophilia
Alcoholism Seizures
Drug Abuse Emotional Problems
AIDS Obesity
Hepatitis Birth Defect(s)

Please explain in relevant detail any of the conditions listed above


3) List age, sex and general health of brothers and sisters: 


4) Have any of your children died? 

D. FEEDING AND NUTRITION

1) Is your child’s appetite usually good? 
2) Is your child's appetite good now?
3) Has there been severe colic or any unusual feeding problems?
4) Do any foods disagree with him/her?
5) For the first 6 months, did you breast or bottle feed? 
6) Does he/she take vitamins?
7) Any herbal supplements? 
 

 

 E. REVIEW OF SYSTEMS

1) Has your child had any of the following?    
  Frequent ear infections? 
  Hearing problems?
  Eye problems? 
  Problems with teeth? 
  Frequent colds or sore throats?
  Asthma, pneumonia, or recurrent cough?
  Heart murmur or any heart problems? 
  Problems with urination? 
  Diarrhea or constipation?
  Convulsions/central nervous system problems?
  Eczema, hives or other skin conditions? 
  Please note any other medical problems:  
 

F. DEVELOPMENT/BEHAVIOR

1) Age your child sat alone (in months)?  months
2) At what age did he/she walk alone?  months
3) Did he/she say any words by 1 ½ years of age?
4) How does this child compare to others his/her age?  
5) Any trouble sleeping?
6) What grade is your child in school? (1st, 2nd)  
7) Does he/she have trouble getting along well with other children?
8) Check if your child has any of the following:
 
Nail Biting Nightmares/Sleep Problems
thumb sucking speech problems
bedwetting discipline problems
bad temper  problems with toilet training
hyperactivity other
 
  Notes on checked boxes or other:

G. SAFETY/ENVIRONMENT

 
1) Do you live in a private house, apartment, condo/townhome, mobile home, other? (circle one)   
2) Do you know the hottest temperature of the water in your pipes? 
3) Is there a working smoke alarm on each floor in your house?   
4) Does your child always use a car seat/seat belt when riding in the car?   
5) Are any smokers in the house?  
6) Are there any problems with the condition of home? (peeling paint, insects, rats, etc.)
7) Does your child always wear a helmet when riding a bicycle, scooter, skateboard, rollerblading, or skating?  
8) Are parents Married, Divorced, Separated, Widowed?  
9) With whom and where does the child reside?  
 
Signature of Patient (if over 18), Parent or legal Guardian Click and hold to sign or use draw on touch screen. 


Date of signature