Pediatric Questionnaire
Page 1
Pediatric Questionnaire
By completing this questionnaire, you will help me better understand your child. The questionnaire provides me with a great deal of important information and allows me to work more effectively and efficiently with you.
Child’s name: ______Date of birth: ______Gender: ______
Parent(s) name: ______
Address: ______
Telephone #: Home - ______Work - ______
Name of person completing form:______
Relationship to child:______
Date form completed:______
I.Referral Question
Who referred you to me?
Why were you referred?
What difficulties is your child experiencing? Medical, developmental, academic, behavioral, social?
How have these difficulties changed over time? Have they worsened, stayed the same, or improved?
What most concerns you about your child?
What questions about your child do you hope to have answered by our work together?
II.Birth History (to be completed by mother, if possible)
Please indicate:
Number of pregnancies you have had:_____
Number of live births_____
Number of stillbirths_____
Number of miscarriages_____
Number of living children_____
Number of deceased children_____
This child was the product of pregnancy number_____
YesNo
Did you receive regular medical care during this pregnancy______
Did you have any problems during this pregnancy?______
If yes, please describe the problem and the time during the
pregnancy it occurred (e.g., diabetes, toxemia, bleeding,
excess vomiting, high blood pressure, weight loss, fever,
accidents):
______
______
Did you smoke cigarettes during this pregnancy?______
If yes, how many packs a day did you smoke? ______
Did you consume alcoholic beverages during this pregnancy?______
If yes, how many drinks per week did you have? ______
Did you take medications during this pregnancy?______
If yes, please list: ______
______
Did you carry this baby to term (37-40 weeks)?______
If no, please indicate the length of pregnancy in weeks: ____
What type of labor did you have (e.g., fast, easy, long, hard)?______
How long in hours did your labor last?______
YesNo
Were there any problems with the delivery?______
If yes, please describe the problems (e.g., emergency C-section,
slow heart rate, fever, cord around neck, etc.):______
______
How much did your baby weigh at birth?______
Did your baby require any special care after birth?______
If yes, please describe the type of care (e.g., blood transfusions,
oxygen, incubator, medications, etc.): ______
______
III.Medical History
Has your child ever been hospitalized?______
If yes, please list age and reason: ______
______
Has your child ever had surgery?______
If yes, please list age and reason: ______
Has your child ever had a serious accident?______
If yes, please describe, including age: ______
______
Has your child ever had a seizure or convulsion?______
If yes, please describe, including ages and medications that
were prescribed: ______
______
If yes, was the seizure associated with a high fever?______
Has your child ever had a head injury?______
If yes, what happened and when: ______
______
Was your child unconscious?______
Was your child dizzy or confused afterward?______
Did your child have a headache afterward?______
Did your child vomit afterward?______
YesNo
Does your child have any allergies?______
If yes, please specify: ______
Does your child have any vision problems or wear glasses?______
If yes, please specify: ______
Does your child have any hearing problems?______
If yes, please specify: ______
Does your child have a history of frequent ear infections?______
If yes, please specify: ______
Does your child regularly take any medications?______
If yes, please specify: ______
Does your child have any sleep problems, such as difficulty falling______
asleep, frequent nighttime waking, or early morning rousing?
If yes, please describe: ______
______
Does your child have any eating problems, such as restrictive food______
preferences, or any recent, noticeable weight gain/loss?
If yes, please describe: ______
IV.Developmental History
At what age did your child…
Sit without help?______Say single words meaningfully?______
Crawl?______Combine 2 or more words?______
Walk without help?______Use sentences?______
Show a clear hand preference?______Which hand?______
Compared to other children, do you feel your child was slower in learning…
YesNo
To talk?______
To understand other people talk?______
To build with blocks, play with puzzles, draw pictures?______
Gross motor skills (walking, hopping, riding bicycle, etc.)?______
Fine motor skills (fastening buttons, zippers, drawing, etc.)?______
Early school-related skills (naming colors, saying alphabet)?______
To sit still for TV or stories?______
To play or socialize with other children?______
V.Family History
Mother’s name: ______Age: ______
Highest level of education completed: ______Occupation: ______
Place of employment: ______
Work hours: ______Work telephone #: ______
Father’s name: ______Age: ______
Highest level of education completed: ______Occupation: ______
Place of employment: ______
Work hours: ______Work telephone #: ______
Step-parent’s name (if applicable): ______Age: ______
Highest level of education completed: ______Occupation: ______
Place of employment: ______
Work hours: ______Work telephone #: ______
Parents are:
Married:______Date: ______
Separated:______Date: ______
Divorced:______Date: ______
Unmarried:______Date: ______
Widowed:______Date: ______
If parents are divorced, who has legal custody? ______
If parents are separated or divorced, please describe physical custody and visitation arrangements: ______
Please list the persons who are currently living in the home with the child:
NameGenderAgeRelationship to Child
______|______|______|______
______|______|______|______
______|______|______|______
______|______|______|______
______|______|______|______
______|______|______|______
Please list family members who are no longer living at home:
______|______|______|______|______|______|______|______|______|______
Is this child a foster child?Yes ______No ______
Is this child adopted?Yes ______No ______
If a foster child or adopted, how long has the child been in your home? ______
If a foster child or adopted, has this been discussed with the child?Yes ______No ______
How long has the child been living in the current home or apartment? ______
How many times has your child moved during the past three years? ______
During the past 12 months, has your family experienced any of the following?
YesNo
Death of a family member:______
Serious illness:______
Unemployment:______
Marital problems:______
Other (please describe ______)______
YesNo
Has your child or family ever been seen by a psychologist, psychiatrist,______
or counselor?
If yes, please describe: ______
Please list anyone in the immediate or extended family who had or is having learning problems in school:
Person (parent, grandparent, brother, uncle, etc.)Type of problem (language, reading math, etc.)
______
______
______
Please list anyone in the immediate or extended family who has experienced or is experiencing behavioral or emotional problems:
Person (parent, grandparent, brother, uncle, etc.)Type of problem (depressed, drug &
alcohol abuse, psychotic, nervous
breakdown, trouble with the law)
______
______
______
Has anyone in the immediate or extended family suffered from:
PersonDescribe problem
Seizures/epilepsy?______Any other neurological
disorder?______Mental retardation? ______
VI.School History
YesNo
Did your child attend preschool?______
If yes, give ages of attendance: ______
Preschool name: ______
Age at kindergarten entrance? ______
Age at first grade entrance? ______
Has your child ever repeated a grade?______
If yes, which grade(s): ______
YesNo
Has your child ever been evaluated for learning problems before?______
If yes, by whom and when: ______
Has your child had a frequent change of schools?______
How many schools has (s)he attended: ______
Current grade placement: ______
School name: ______
Address: ______
City: ______State: ______Zip: ______
Telephone #: ______
Has your child ever received any of the following services?
YesNoAge or Grade
Speech/language therapy:______
Physical therapy:______
Occupational therapy:______
Learning disabilities tutoring:______
Counseling:______
Other (please describe: ______)______
Has your child ever been placed in a special education program?
Developmentally Handicapped:______
Severely Behaviorally Handicapped:______
Multiply Handicapped:______
Specific Learning Disabilities:______
Thank you for completing this questionnaire. Your assistance is greatly appreciated.
______
(signature of parent/guardian)
______
(street address)
______
(city, state, zip code)
______
(telephone number)