North Franklin Internal Medicine & Pediatrics Clinic: Pediatric New Patient Questionnaire
To be filled out by parent
Child’s Name: Date of Birth:______
Parent/Guardian Name: Parent/Guardian Name:______
Names of Adults Living at Home (and relation to patient)
______
______
______
______
A. Pregnancy and Birth3. List name, general health, sex & age of siblings:
Name M/F Age:______
1. Mother’s age at birth . Name M/F Age:______
2. Maternal illness/ problems during pregnancy? No YesName M/F Age:______
______Name M/F Age:______
______
4. Circle any diseases that this child’s parents,
3. Did mother take any meds other than vitamins and iron? grandparents, siblings, aunts, uncles, cousins have had:
4. Was the baby on time (>37 weeks)?No Yesanemia, asthma, allergies, eczema, diabetes, high blood
5. Was the baby breech?No Yespressure, heart trouble, heart attack (less than 35 yrs),
6. What was the birth weight?______high cholesterol/triglycerides, tuberculosis, mental illness,
7. Birth hospital and Obstetrician?drug problems, alcoholism, inherited illness, cancer, HIV
______AIDS, learning disorder, attention deficit disorder or
______Hyperactivity, strabismus, childhood seizures, sickle cell
Disease, high lead level/poisoning, others
B. Past Medical History______
______
1. Where has your child gone for check-ups last?______
______4. Have any of your children died?No Yes
2. Date of last check-up?______
3. Medications taken regularly/ currently?No YesD. Feeding and Nutrition
Which ones? (include over-the-counter meds)
1. Was there severe colic or any feeding problems during the
______first three months?No Yes
______2. If breastfed, for how long? ______
______3. Does he/she take vitamins or fluoride?No Yes
______4. Does your child use homeopathic or herbal medicines?
______No Yes
4. Allergic reaction to meds, food, insects?No Yes5. Other infections?No Yes
Which ones?______6. Asthma, pneumonia, recurrent cough?No Yes
5. Any serious reactions to immunizations?No Yes7. Heart murmur or heart problems?No Yes
Which ones?______8. Problems with urination, urine infections?
6. Any hospitalizations besides birth?No YesNo Yes
For what?______9. Frequent diarrhea or constipation?No Yes
______10. Convulsions or other problems with the nervous system?
______No Yes
7. Any serious injuries?No Yes11. Eczema, hives or other skin conditions?
What kind?______No Yes
______12. Anemia or other blood problems?No Yes
______13. Problems with teeth?No Yes
C. Family History
1. Is first parent in good health?No Yes
2. Is second parent in good health?No Yes
Patient Name:______
Please list any other medical problems:
______
______
______
List any sub specialists your child has seen:
______
______
______
F. Development History and Behavior
1. Age he/she sat alone? Age walked alone? ______
2. Was he/she saying words by 18 months?Yes No
3. Does he/she have trouble with coordination?Yes No
4. Does he/she have trouble with coordination?Yes No
5. Does he/she have trouble with walking?Yes No
6. Does he/she have trouble speaking?Yes No
7. Does he/she have nightmares or trouble sleeping?Yes No
8. Does he/she have trouble with bed wetting?Yes No
9. Does he/she have trouble with potty training?Yes No
10. Any concerns about his/her moods?Yes No
11. Any other developmental or behavior concerns? ______
______
12. What grade is he/she in? ______
13. Has he/she had any trouble in school?Yes No
14. Has he/she ever been held back in school?Yes No
15. Circle if your child has had any of following: thumb sucking, hyperactivity, problems with discipline
16. Does the child receive social services?Yes No
G. Safety/Environment
1. Are the parents of the child (CIRCLE): married, divorced, separated, deceased
2. The child lives with (CIRCLE): both, one (joint custody), guardian, foster, stepmother, stepfather, other
3. Is the child adopted?Yes No
4. The child is also in (CIRCLE): daycare, preschool, with nanny, with relatives, school
5. Are there any pets at home?Yes No
6. Is the child exposed to smokers?Yes No
7. Do you have a pool, spa or pond?Yes No
8. Does he/she always use a car seat or seatbelt?No Yes
9. Does he/she always wear a helmet when bicycling or skating?
No Yes
Is there a gun in the home?Yes No
Do you have well water?Yes No
What decade was your home built (if known)? ______
Are you concerned for your child’s safety for any reason?
Yes No
H. Records
1. Do you have record immunizations?No Yes
IF YES PLEASE PROVIDE TO RECEPTIONIST TO COPY AND INCLUDE IN THE MEDICAL RECORD