Children's Health Questionnaire

An in-depth pediatric intake that covers family background, birth history, vision, school performance, and behavior so a doctor's office can build a complete picture before the first visit.

Use this template

Page 1

Appointment Date

Child's Name

Nombre

Apellido

Nickname

Gender

Female Male Prefer not to say

Home Address

Dirección

Ciudad

Estado / Provincia

Código postal

Home Phone Number

Cell Phone Number

Child's Birthdate

Grade

Age

Child's Dominant Hand

Right Left Ambidextrous

Is Your Child

Shy Outgoing A Mix of Both

Is Your Child Especially Afraid of Doctors?

Yes No

How Did You Hear About Our Office?

Were You Referred to Our Office?

Yes No

If Yes, Whom Should We Thank for the Referral?

Nombre

Apellido

Name of School

Teacher's Name

Nombre

Apellido

Principal

Father/Caregiver's Occupation

Cell Phone Number

Mother/Caregiver's Occupation

Cell Phone Number

Person Responsible for Patient's Account

Nombre

Apellido

Relationship to Patient

Home Address (if Different From Patient's)

Dirección

Ciudad

Estado / Provincia

Código postal

Home Phone Number (if Different From Patient's)

Cell Phone Number

Paediatrician Name

Date of Last Exam

Child's Current State of Health

Would You Like Us to Send a Report of Today's Findings to Your Child's Paediatrician?

Yes No

Is Your Child Allergic to Any Foods or Medications?

Please List Any Serious Illnesses, Bad Falls, Fevers, Etc.

Any Reactions to Immunization(s)?

Yes No

Please Explain

Is Family History Unknown?

Yes No

Has Your Child Seen a Neurologist?

Yes No

Has Your Child Seen a Psychologist?

Yes No

Has an Occupational/Speech/Physical Therapy Evaluation Been Performed?

Yes No

Current Diet

Regular Special Restricted

Is Your Child Active

Very Active Moderately Active Not Very Active

How Active

Low Moderate High

Are There Periods Of

Hyperactivity Lethargy None

Please Explain

Full Term Pregnancy?

Yes No

How Many Weeks

Mother's Age at Birth

Under 20 20-29 30-39 40 or Older

Did the Mother Experience Any Health Problems During Pregnancy?

Yes No

Please Explain

Natural Birth?

Yes No

Length of Labour

Induced?

Yes No

Were Forceps Used?

Yes No

Cesarian Birth?

Yes No

Was the Delivery

Normal Difficult

Any Complications Before, During, or Immediately Following Delivery?

Yes No

Please Explain

Birth Weight

Apgar Score (1 Minute)

Apgar Score (5 Minutes)

Was There Ever Any Reason or Concern Over Your Child's General Growth or Development?

Yes No

If Yes, Why?

Developmental Milestones

Sitting (Age)

Crawling (Age)

Walking (Age)

First Spoke at What Age

First Words

At What Age Did Your Child Use Short Sentences?

Was Speech Clear to Others?

Yes No

Is Speech Clear Now?

Yes No

Can Your Child Ride a Bike?

Yes No

How Old Were They When They Learned to Ride a Bike Without Training Wheels?

Page 2

Why Do You Feel Your Child Needs a Visual Assessment?

How Long Has the Problem/Difficulty Been Observed?

Has Your Child Had an Eye Exam?

Yes No

Optometrist's Name

Date of Last Exam

Were Glasses Recommended/Prescribed?

Yes No

Used For

Reading Distance All the Time

Are the Glasses Worn Regularly?

Yes No

Does Your Child Have an Eye Turn (Strabismus) or a Lazy Eye (Amblyopia)?

Eye Turn (Strabismus) Lazy Eye (Amblyopia) Neither

Tell Us More About the Eye Turn: At What Age Was It First Noticed, Did It Happen Suddenly or Gradually, Is It Improving or Worsening, and Does It Reduce With Glasses?

Has Your Child Had Surgery for the Eye Turn? Please Note the Age, Number of Operations, Which Eye Was Operated On, and Whether You Were Satisfied With the Results

Tell Us More About the Lazy Eye: At What Age Was It Discovered, Was Patching Used and for How Long, and Was Atropine Ever Prescribed (Percentage, Frequency, and Eye)?

Is There Any Evidence From School, Psychological, or Other Tests That May Indicate Some Visual Problem May Be Present?

Yes No

Please Explain

List Any Other Complaints Your Child Makes Concerning Their Vision

Page 4

Additional Questions

Type a Question

Yes No

Name

Nombre

Apellido

Phone

Name

Nombre

Apellido

Phone

Name

Nombre

Apellido

Phone

Name

Nombre

Apellido

Phone

How Should We Contact You?

Phone Email Text Message

Confirmation and Signature

I Certify That the Information Provided Is True and Complete

Signature

Sign here

Name of Person Signing

Nombre

Apellido

Date

Relationship to Patient

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Children's Health Questionnaire

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