Initial History Questionnaire

Do you consider your child to be in good health?

Yes

No

Does your child have any special care needs?

Yes

No

Has your child ever been hospitalized?

Yes

No

Is your child allergic to medicines, drugs, or food?

Yes

No

During pregnancy, did the mother:

Any complications during or after birth?

Yes

No

Was the mother positive to any of the following labs?

Did the baby go to NICU?

Yes

No

After birth, did the baby received any of the following?

Vitamin K

Hepatitis B

Erythromycin (ophthalmic)

All were declined

ENT

Pulmonary

Gastrointestinal

Hematology

Eyes

Eye problems

Cataracts

Vision impairment

Heart

Heart murmurs

High blood pressure

Urology

Urinary tract infections

Bedwetting over 5y/o

Kidney or bladder problems

Neuro

Head injury

Seizures

Concussion

Endocrine

Thyroid problems

Diabetes

Metabolic problems

Skin

Acne

Eczema

Gynecology

STD's

Problems with period

Surgery

Yes

No

Behavior

Orthopedics

Bone fractures

Joint pain

Muscle spasms or pain

Child's current living situation?

Family history 3

Family history 2

Family history 1

Donde tu familia es nuestra familia

GENERAL

HISTORIA DEL NACIMIENTO

HISTORIAL MÉDICO PASADO

HISTORIA SOCIAL Y FAMILIAR

¿Alguno de los padres, abuelos, tías, tíos, hermanos o hermanas de su hijo ha tenido alguna de las siguientes afecciones?