Columbia Medical Practice, P.C.

Pediatric - New Patient Questionnaire

Child's Name: ________________________________________ Birth Date: ____________

Child's Nickname: ______________________________________________ Sex: ________

Father's Name: _____________________________ Occupation: _____________________

Mother's Name: _____________________________ Occupation: ____________________

Home Address: ____________________________________________________________

Parent's Marital Status: _____________________________________________________

Phone Number: Home: ______________________________________________________

Father's Work: _______________________ Mother's Work: _______________________

A. PREGNANCY AND BIRTH (This child):

	Circle Correct Answer
1. Did you have an illness during your pregnancy?	NO    YES
2. Did the baby come on time?	YES    NO
3. What was the birth weight?	___________
4. Did your baby have any trouble starting to breathe?	NO    YES
5. Did the baby have any trouble while in the hospital?	NO    YES
6. Did the baby have any jaundice?	NO    YES
7. Did you take any medications during this pregnancy?	NO    YES
8. Did the baby go home from the hospital with you?	YES    NO
9. This delivery was: Vaginal ____   Ceasarean ____

B. FEEDING:

1. Type of feeding: Breast ____   Formula ____
2. Was there severe colic or any unusual feedings problems the first 3 months?	NO    YES
3. Is your child's appetite usually good?	YES    NO
4. Is it good now?	YES    NO
5. Do any foods disagree with your child?	NO    YES
6. Does your child often have diarrhea?	NO    YES
7. Has constipation ever been much of a problem?	NO    YES
8. Does your child take vitamins?	YES    NO

C. FAMILY HISTORY:

1. Circle any of the following diseases that this child's parents, grandparents, aunts, uncles, brothers, sisters have had:

Tuberculosis	Diabetes	Asthma
Allergy	Seizures	Cancer
Mental Illness	Inherited Diseases	Blood Diseases
Stroke	Hypertension	Heart Problems

2. Are the child's parents both in good health?	YES    NO
3. Have any of your children died?	NO    YES

D. HEALTH HISTORY:

1. Has your child had as many as three bouts of ear trouble?	NO    YES
2. Does he have any trouble with urination?	NO    YES
3. Has he ever had a convulsion?	NO    YES
4. Does he hear well?	YES    NO
5. Has he had any trouble with his eyes?	NO    YES
6. At what age did he sit alone?	___________
7. At what age did he walk alone?	___________
8. Did he say any words by the time he was 1-1/2 years old?	YES    NO
9. Does he have any trouble sleeping now?	NO    YES
10. Has your child had any significant illnesses?	NO    YES
11. Has your child had any operations?	NO    YES
12. Has your child had any hospitalizations?	NO    YES
13. Has he ever had eczema or hives?	NO    YES
14. Has he ever had wheezing or asthma?	NO    YES
15. Does he tend to have a stuffy nose or "constant cold?"	NO    YES
16. Has he had any allergies or reactions to any medications or injections?	NO    YES
17. Is he doing well in school?	YES    NO
18. Does he get along well with other children?	YES    NO

19. Underline any of the following that your child has:

Nail biting	Irritability	Speech Problems
Thumbsucking	Wet Beds	Breath Holding
Nightmares	Won't Mind	Jealousy

E. IMMUNIZATIONS

Please fill in the dates of any immunizations your child has had:

DPT	(Diptheria - Whooping Cough - Tetanus): ___________
DTaP	(Diphtheria, Tetanus, Acellular Pertussis): ____________
OPV	(Oral Polio Vaccine): ______________
DT	(Diphtheria - Tetanus): _____________
MMR	(Measles - Mumps - Rubella combined): ____________
Measles:	___________
Mumps:	___________
Rubella:	___________
Hib	(Hemophilus influenzae type B, "miningitis" vaccine): __________
Hepatitis B:	___________
Varicella	(Chickenpox): __________
Other Immunizations:	_________________________________________________________

F. SAFETY:

1. Does your child regularly use an approved car seat or seat belt?	YES    NO
2. If a car seat is used, is it properly installed?	YES    NO
3. Do you have Syrup of Ipecac in your home?	YES    NO
4. Do you have a smoke detector or a fire alarm?	YES    NO
5. Do you have a fire extinguisher?	YES    NO
6. Is your water temperature set at 120-130 degrees F to decrease accidental scalds?	YES    NO
(YOU SHOULD DO SO IF NOT)
Do you have window and stairway guards to prevent falls?	YES    NO