Annual Questionnaire

Patient Name:  Date of Birth: 
  

Family History

Relationship Name Living (Y/N) Age Major Medical Problems and/or Cause of Death
Father
Mother
Siblings
 
 
 

Specifically have any of the child's relatives had the following conditions: (mother, father, brother, sister, grandmother or grandfather only) Please indicate maternal or paternal grandparent.

Condition Relative   Condition Relative
Diabetes   Cancer
Mental illness   Skin problems (eczema)
Kidney problems   Heart disease
Seizures   Stroke
Allergies/asthma   Anemia
Bleeding problems   HIV
High blood pressure   Eating disorder
Lung disease   Substance abuse
Anxiety/depression   Headaches
Thyroid disorder   Scoliosis
High cholesterol   GI illness
Sickle cell   Other:
Does your child have any specific communication needs? For example: hearing impairment, speech delay, autism
Are there any religious or cultural factors that you would like us to take into account when planning your child's healthcare?

Has your child had any of the following

Chicken pox Wears glasses/contact lenses Asthma
Measles Heart murmur Allergies
Mumps Kidney or bladder infection Broken bones
Head injury Bed wetting (>6 years old) Frequent ear infections (>4 year)
Seizures Diabetes Frequent throat infections (>4 year)
Thyroid disorder Other:  
Has your child ever been hospitalized or had surgery?
If yes, list date and reason:


Childs Social Characteristics

Sports / Hobbies: Pets:
Hours of TV/Electronics Each Day:
(phone, tablet, video games)
Exposure to Second Hand Smoke:
Special Diet: Firearms in Home:
Weekly Hours of Outdoor Activity: Wears Sunscreen:
City Water or Well Water Wears Seatbelt Car Seat Booster
List Household Members:
Mother’s Place of Employment & Type of Work:
Father’s Place of Employment & Type of Work:


Medications

Please list any medications that your child takes including over the counter medications, herbs, vitamins, supplements and homeopathic remedies. Include dose and frequency


Specialty Providers

In order that we can best coordinate your child's care, please list any medical providers the child sees outside of this practice and list the year that they last saw them


Health Literacy

Please answer the following questions:
I feel that I have a thorough understanding of the instructions that doctors and nurses give me about my health
I feel that I remember the instructions given to me at the doctor’s office when I get home
I feel that I have a strong understanding of medical language