North Franklin Internal Medicine & Pediatrics Clinic: Pediatric New Patient Questionnaire

North Franklin Internal Medicine & Pediatrics Clinic: Pediatric New Patient Questionnaire

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 YesNo 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