Pediatric Patient History Questionnaire

Langeloh Family Healthcare

Pediatric Patient History Questionnaire

Patient Name _____________________________________ Date of Birth _______________

Parent Name ________________________________________ Phone #____________ Current Date _______________

Welcome to our office. This questionnaire has been designed so that we can both review your child’s medical history and factors in her/his life that affect health. It is long and detailed! Some questions may not apply, depending on the age of your child; you may skip these. All information collected will be kept strictly confidential. Thank you for your patience.

General Health: rexcellent rgood rfair rpoor

Past Medical Illnesses:

(Please list any illnesses that have required hospitalization and any other significant health problems)

rproblems during pregnancy, birth, or in the newborn period.

Birth Weight___________ rC-section rVaginal Birth

rBreast fed How long: _____________ rFormula fed Which brand: _______________

raccidents, broken bones, other serious injury

rallergies (asthma, eczema, hay fever), food allergies

ranemia (low blood count) or bleeding problems

rbladder/kidney problems: frequent infections, control problems (if unusual for child’s age)

rgrowth problems: poor weight gain, etc.

remotional problems: depression, ongoing or past abuse concerns, behavior problems rheart problems, murmur, etc.

rgastrointestinal problems: frequent upset stomach, diarrhea

rlung problems: pneumonia, asthma, etc.

rneurologic: seizures, developmental or learning disabilities, cerebral palsy, headaches rskin problems

rsleep problems: insomnia, night terrors, etc.

rtuberculosis (or positive skin test)

Details of any of the above checked or any specific diagnosis that has been given to patient: ____________________________________________________________________________

____________________________________________________________________________

Are his/her immunizations up to date? ryes rno

When was his/her last dental visit?______________

*Please bring immunization record to first appointment.

Past Surgery (include approximate date and type of procedure): ____________________________________________________________________________

____________________________________________________________________________

Current medications (include over-the-counter medicines, sleeping pills, aspirin, laxatives, vitamins, etc. and indicate dose and frequency): ________________________________________________________________________________________________________________________________________________________

Allergies to any Medication: (list medication and reaction): ________________________________________________________________________________________________________________________________________________________

Family History:

Is your child adopted or from a donor insemination . . . . . . . . ryes rno

Please list medical history for biological relatives:

Relationship Name Age Living/Deceased Medical Problems

Mother ____________________ ___ ________ ______________________

Father ____________________ ___ ________ ______________________

Brothers/Sisters ____________________ ___ ________ ______________________

____________________ ___ ________ ______________________

Is there any history in the family of the following illnesses?

(Include mother(M), father(F), sister(S), brother(B), paternal grandmother (PG), paternal grandfather(PG), maternal grandmother (MG), maternal grandfather (MG) aunts(A), uncles(U), cousins(C).)

YES NO UNSURE WHO?

Alcoholism or drug abuse r r r ______________________

Allergies, severe r r r ______________________

Attention deficit/learning disorders r r r ______________________

Bleeding problems r r r ______________________

Blood clots in legs or chest r r r ______________________

Depression or mental illness r r r ______________________

Diabetes r r r ______________________

Cancer r r r ______________________

(What organ(s)?) ________________________________________________________

Heart problems, before age 50 r r r _____________________

Kidney disease r r r ______________________

Liver disease r r r ______________________

Lung disease r r r ______________________

Mental retardation r r r ______________________

Tuberculosis r r r ______________________

Other: r r r ______________________

Social History:

Please list everyone who lives in the home with this child and note relationship:

Full Name: Age: Relationship: _____________________________ _________ ___________________________________ _____________________________ _________ ___________________________________ _____________________________ _________ ___________________________________ _____________________________ _________ ___________________________________ _____________________________ _________ ___________________________________

Brothers/sisters and parents not living in the home:

Does your child get along well with her/his siblings? . . . . . . . . . . . . . . . . . . . . ryes rno Are you currently providing care for a disabled or elderly family member? .. . . . ryes rno

School history

Is your child currently in school?. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ryes rno r Home school r Public school r Private school

What grade level? __________________________________

Has she or he had any difficulty in school and, if so, what was the problem? ________________________________________________________________________________________________________________________________________________________What action was taken? ________________________________________________________________________________________________________________________________________________________

Does your child play well with other children?. . . . . . . . . . . . . . . . . . . . . . . . ryes rno How many hours of television/videos does your child watch every day? _________________

Discipline

What is your method of discipline? _______________________________________________

Is discipline a problem for you? _________________________________________________

How do adults in the home deal with conflict? ______________________________________

Abuse

Has your child ever experienced physical or sexual abuse?. . . . . . . . . . . . . . . . ryes rno Did she or he receive any counseling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ryes rno

Travel: Has your child ever been in (or is he/she from):

r a foreign country? r another region of the United States?

Timeline: Please provide a detailed timeline from birth until now: (including any diagnosis, when and where of diagnosis/any treatments or medications.) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Diet: Please list what your child eats weekly, with approximate amounts. (Top 5 foods)

If you are breast-feeding, please list your diet:

Breakfast Lunch Supper Snacks/Drinks

Does your child follow a special diet? (vegetarian, low salt, low fat etc.). ryes rno

How many times a week does your family eat red meat? _____________________________

How many servings of fruit or vegetables does your child eat every day?_________________

What do you give your child for snacks? __________________________________________

How many sodas (Coke, Pepsi, etc.) does your child drink every day? ___________________

How many servings of chips, candy does your child eat every day? _____________________

Has weight ever been a problem for your child? …………………………………………………………..ryes rno

Are you concerned about your child under eating or being preoccupied with weight? . . . ryes rno Has weight ever been a problem for the parents or other adults in the home?...................ryes rno Has your child ever had to limit certain foods because of a bad reaction to those foods?. . ryes rno

Which foods, what reaction, and do they still avoid those foods: _____________________ _________________________________________________________________________ _________________________________________________________________________

Exercise: Does your child exercise daily? …………………………………………………. ryes rno

What kind of exercise/play does he/she enjoy? _____________________________________

Does she/he have safety equipment for bicycles, roller skates, etc.? . . . . . . . ryes rno

Hobbies, other activities (church groups, sports, musical instruments, etc.): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other providers involved in your child’s care

Do you see other health care providers for your child (such as a therapist, other physicians, chiropractors, acupuncturists, herbalists, etc.) on a regular basis? ryes rno

Name Profession

_____________________________ ______________________________________

Would you like your medical provider at the clinic to consult with or coordinate your child’s care with her/his other provider(s)? . . . . . . . . . . . . . . . . . . . . . . . ryes rno

** PLEASE indicate by checking above professions.

Current symptoms

Check symptoms or problems your child has now or occasionally, and write details below:

Allergies: rsinus congestion rskin rashes rasthma

Nervous system problems: rfainting rdizziness rblurry/double vision rhearing problems

Stomach problems: rindigestion rabdominal pain rdiarrhea rconstipation rblood in stools

Lung problems: rcough rshortness of breath rwheezing r hoarseness

Heart problems: rchest pain rpalpitations r trouble breathing lying flat r fainting spells

Circulatory problems: rleg swelling rleg cramps with exercise or at night

Skin: rrash rchanging mole(s) ritching rwarts

Growth problems r Joint problems r back pain

Bladder/kidney problems: rfrequent urinary tract infections

rloss of control of urine(accidents)(inappropriate for age) rproblems with foreskin or circumcision

Problems with sexual development: rbreast development rhair growth

rperiods starting before expected

Sleep problems: rinsomnia rdaytime sleepiness rsnoring rBehavior problems rlearning problems rdevelopment problems

Development

At what age did your child sit?________________________

At what age did your child walk? ______________________

At what age did your child talk? ______________________

Does your child wear glasses? ryes rno Contact lenses? ryes rno

Braces? ryes rno

Please provide IN GREAT DETAILS the problems checked above.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please summarize your concerns about your child’s health and prioritize what you would like Langeloh Family Healthcare to help you with. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________