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1、Date of Visit: _Your Name: _Childs Name: _Relation to Child: _THIS FORM IS FOR MEDICAL RECORD USE ONLY AND WILL REMAIN CONFIDENTIAL. PLEASE ANSWER EACH QUESTION TO THE BEST OF YOUR ABILITY.Vital InformationChilds Date of Birth:_ _Boy _Girl BirthplaceCity/State_Hospital_ Other_Mothers Name_ Birth Dat
2、e_Occupation _Ht_ Wt_Fathers Name _Birth Date_Occupation_ Ht _ Wt_Names of living brothers and sisters Birth dates_Was child adopted? _Yes _No At what age? _ If adopted, country of origin_Religious Preference_PregnancyNumber of pregnancies before this one_ How long was this pregnancy _weeks?How many
3、 months pregnant when prenatal care was begun_Were there any of the following illnesses or problems?_ Rubella (measles) _ Accident/Injury _ Bleeding _ Swelling _ High Blood Pressure _ Sugar in Urine _Excessive weight gain_ Other infections Explain: _Medicines or drugs used during pregnancy:_Smoking
4、while pregnant _None _ Moderate _ HeavyAlcohol while pregnant _ None _1 per weekBirthHow long was labor? _ Was labor induced? _At delivery (check all that apply):_ Breech (feet or bottom first) _ Cesarean section _VBAC_ Breathed and cried immediately _ Resuscitated _ On oxygenDid baby require: _ spe
5、cial nursery _blood transfusion _ antibiotics _ lightsDid baby have:_ breathing problems _yellow jaundice _Other _At birth: Weight_ Length _ Apgar score _ Discharge wt _Length of hospital stay: _Describe any problems_Speedway Pediatric Initial Health QuestionnaireediatricInitialHealthQuestionnaireDa
6、teofVisit小儿初始健康问卷访问日期Family BackgroundEthnic origin/Race: Mother _ Father: _ Married _ Living together _ Separated _Divorced _ SingleChild lives with: _ Both parents _Mother _ Father _ GuardianOther members of household: _Age of home or apartment? _ Any pets? _Has any parent, brother or sister died?
7、 _ Who? _Cause of death? _ Age _List family illnesses known and the family member:_Medical HistoryPlease check the diseases that your child has had and give age._Measles, Rubella_ _ Anemia _Mumps _ _ Heart Disease _Chickenpox _ _ Crossed eyes_Convulsions/ Seizures _ Eczema _ _ Allergies/Hay fever _A
8、sthma _ _ _Whooping cough _ _Pneumonia_ _Rheumatic fever _ Hepatitis _ Strep throat _ _ Ear Infection _ Other Illnesses_Has your child ever been injured? _ Age_Injury _Any fractures? _ Which bones? _Any loss of consciousness or concussion?_Any accidental poisoning? _ Age_ Substance? _ Has your child
9、 had surgery?_What age? _Type of operation _Has your child been hospitalized other than for the above? _Describe_Has your child ever had a blood transfusion? _ Age _Does your child take any medications regularly?_Does your child take any of the following: _Vitamins _ Fluoride Food supplements_Has yo
10、ur child worn? _ Glasses _ Contact lenses _ Dental braces _ Leg braces_ Corrective shoes _ Orthotics In shoes _ Other bracesDoes your child have any of the following: _ Frequent headaches _ Pinkeye_ Trouble hearing_ stuffy nose most of the time_ Chronic cough_ Heart murmur_ Frequent stomachaches_ Po
11、or appetite_ Bloody, red or brown urine_ Joint pains or swelling_ Inability to get to sleep_ Excessive thirst_ Signs of sexual development before age 9_ More than two earaches a year_ Frequent nosebleeds_ More than 6 colds a year_ Shortness of breathe with exercises_ Constant or frequent fatigue_ Fr
12、equent diarrhea or constipation_ Frequent urination or accidents_ Frequent bed-wetting after age 5_Dizziness or fainting spells_ Frequent nightmares or sleepwalking_ Excessive weight gain_ Allergies_ _Growth and DevelopmentAt what age did your child:Sit alone _ Walk alone _ Feed self _Talk (2-3 word sentences) _ Dress self_Toilet trained: Day_ Night_School age child: Current grade _ Days missed this year _School Problems: _ reading, writing _ behavior_ special needs Any other behavior problems at home?_Describe_ediatricInitialHealthQuestionnaireDateofVisit小儿初始健康问卷访问日期
