Pediatric Questionnaire
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- Virgil Walters
- 5 years ago
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1 1 Pediatric Questionnaire Child s Name: First Last Middle Initial Parent(s) Name(s): Address: Street City State Zip Phone: Work: Cell : Fax: Child s birth date: Child s Sex (Circle One): Male/Female Social Security Number (Optional): Primary Care Physician: Name City State Zip Phone # Health insurance: ID No.: Referred by: Siblings: Name Age Sex Birth Date Name Age Sex Birth Date Name Age Sex Birth Date Name Age Sex Birth Date Parent s occupation(s): Diagnoses or explanation given to you about your child: (Date of diagnoses: / / ) Other problems to be addressed:
2 PERSONAL INFORMATION (Continued) 2 Describe your child to me, including his/her history. Please be as detailed as possible. When did you first notice your child s problem? What did you first notice? Was the onset of your child s problem sudden or gradual? Was there an event or illness that you or others think brought on your child s symptoms? Please make notation of any other event, action, etc. that you think may have some bearing/relationship to your child s condition. Again, be as detailed as possible and do not hesitate to mention anything, no matter how small or insignificant, that you believe is related to your child s problem(s):
3 3 CHILD S MEDICAL HISTORY PRIMARY DOCTOR(S) Name Phone City THERAPIST(S) Speech - Occupational - Physical Other Name Type Phone City Hrs/Wk Specialists NUTRITIONIST DIGESTIVE HEALTH Does child have periodic loose stools/diarrhea Yes No Offensive Gas Yes No Undigested Food in stools Yes No Is you child potty trained Yes No Does your child suffer with reflux/heartburn Yes No Is your child currently taking an acid-blocking medication such as Tagamet, Pepcid, etc. Yes No Did occurrence of digestive problems occur following a particular vaccine Yes No Unsure Does your child produce formed stools Yes No Have they ever produced formed stools Yes No
4 ANTIBIOTIC HISTORY 4 How many courses of antibiotics has your child received in lifetime (approx): Main reason for antibiotic use: Ear Infections Bronchitis Pneumonia Sinus Infection Intestinal Infection Other (please explain) Was your child ever treated for a yeast infection following antibiotic use PRE-NATAL HISTORY Maternal age at delivery: years Antibiotics during pregnancy: Illnesses during pregnancy: Medication during pregnancy: Other complications during pregnancy: High Blood Pressure Seizures Diabetes Bacterial Infections Viral Infections Other Please explain: Does Mom know her Rh status (+ or -) Blood Type Did Mom receive Rhogam during pregnancy Yes No Did Mom receive any vaccinations during pregnancy No Yes, which ones Complications during labor and delivery: Mode of delivery: C-section/vaginal? If C-section, explain why: If vaginal delivery, did you have forceps/vacuum? Was there any concern for birth trauma Medication(s) during labor and delivery? Full term/premature? (Circle one) How many weeks? Complications after delivery? Medications given to child during hospital stay? Did Mom receive any vaccinations after pregnancy while breastfeeding No Yes, which ones
5 MOTHER S MEDICAL HISTORY 5 Low Thyroid Thyroid Cancer Parathyroid problems Night blindness (difficulty seeing at night) Autoimmune Disorders (Lupus, Connective Tissue, Rheumatoid Arthritis, Autoimmune Thyroid) Mercury Fillings in Mouth Dental work that contains Nickel Other, please explain Did Mom have any dental work done during pregnancy Yes No Did mom have mercury fillings removed while breastfeeding child Yes No DIETARY/NUTRITIONAL HISTORY Breast-fed? Yes/No If yes, how long? Bottle-fed? Brand of formula? Begun at what age? For how long? Foods? Begun at what age? First foods? Whole milk? Yes/No If yes, begun at what age? Known allergies to food? (Please list): Suspected sensitivities to foods? (Please list): Food cravings? (Please list): FOODS MY CHILD EATS (Place x in appropriate column) Food Daily 3 5 times/ week 1 3 times/ week Never or almost never Used to eat a lot but no longer does Cookies Candy Sweet foods Caffeine (soda, tea, etc.) Chocolate Milk: Whole 2 % 1 % Skim Cheese Ice Cream Salty Foods Meat Pasta Bread: White Wheat Other
6 Check the most appropriate description below of your child s diet: 6 Mostly baby foods Mostly carbohydrates (bread, pasta, etc.) Mostly dairy (milk, cheese, etc.) Mostly meat Mostly vegetarian (vegetables, fruits, grains, etc.) Other. Describe: Please describe your child s stool pattern (Examples: daily, foul, large, mushy, etc.): Please list the foods and beverages normally consumed by your child for three typical days: DAY 1 Breakfast: Morning snack(s): Lunch: Afternoon snack(s): Dinner: Other DAY 2 Breakfast: Morning snack(s): Lunch: Afternoon snack(s): Dinner: Other DAY 3 Breakfast: Morning snack(s): Lunch: Afternoon snack(s): Dinner: Other Is child on a Gluten Free Diet Yes No Is child on a Casein Free Diet Yes No Has child benefited by being on a GF/CF diet? Is child on a Specific Carbohydrate Diet? Is child on a Low Oxalate Diet?
7 7 DEVELOPMENTAL HISTORY Please list age when following skills were mastered and any problems associated with these skills: First words: (Age: ) Phrases or sentences: (Age: ) Pulling to stand: (Age: ) Walking: (Age: ) Sitting up: (Age: ) Crawling: (Age: ) Running: (Age: ) Walking up/down steps without help: (Age: ) Jumping: (Age: ) Learned to pedal: (Age: ) Rode 2-wheel bicycle: (Age: )
8 Immunizations 8 Please indicate date and any reactions for those immunizations that your child has received. If exact date isn t known, please approximate. Bowel refers to any bowel symptom such as diarrhea. Swelling refers to the site of the injection. Diptheria/Pertussis/Tetanus Date Bowel Swelling Crying Seizure Irritable Fever Other DPT 1 DPT 2 DPT 3 DPT 4 DPT 5 Adult Diptheris/Tetanus Paediatric Diptheris/Tetanus H Influenza Type B Date Bowel Swelling Crying Seizure Irritable Fever Other Hib 1 Hib 2 Hib 3 Hib 4 Polio (circle Oral or Injection) Date Bowel Swelling Crying Seizure Irritable Fever Other OPV 1 / Injection 1 OPV 2/ Injection 2 OPV 3/ Injection 3 OPV 4/ Injection 4 OPV 5/ Injection 5 Measles/Mumps/Rubella Date Bowel Swelling Crying Seizure Irritable Fever Other MMR 1 MMR 2 Hepatitis B Vaccine Date Bowel Swelling Crying Seizure Irritable Fever Other HBV 1 HBV 2 HBV 3 Prevnar (pnemococcal) Miscellaneous Date Bowel Swelling Crying Seizure Irritable Fever Other Varivax (chicken Pox) Tine Test Flu Vaccine Interviewed by
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