Stony Brook Medicine



Pediatric Outpatient History QuestionnaireReason for referral: _________________________________________________________________________________________________Birth History:Birth weight: ________________________ Full term:□ Yes □ No Premature:Gestational Age: ______ weeksVaginal delivery:□ Yes □ No Complications:□ C-section□ Breech□ Failure to progress□ Fetal Distress□ Other: _____________Mother’s age at delivery: _____________Baby’s birth order:□ 1st□ 2nd □ 3rd □ 4th□ 5th □ 6th Regular newborn nursery:□ Yes □ No Neonatal intensive care unit: □ Yes, how long: _________ □ No Discharge from hospital with mother: □ Yes □ No Development History:Did child walk by age 14 months:□ Yes □ No Did child speak short phrases by age 24 months:□ Yes □ No At what age (months) did the child speak first word: _____________ short phrases: __________________roll over: _________ crawl: __________ sit: ___________ walk: ____________ ride tricycle: ___________Has your child had any delayed milestones: _________________________________________________Child enrolled in an Infant (Early Intervention) Program: □ Yes □ No Why/What were the problems: ____________________________________________________________Education History:Present grade: _____________ Attend preschool:□ Yes □ No Therapeutic (special education):□ Yes □ No Name of School: ________________________________________________________________________Is child in regular class:□ Yes □ No Special Education:□ Yes □ No Resource Room: (□ reading □ math □ all)□ Yes □ No Has child ever failed a grade:□ Yes □ No Social History:Place of birth: _________________________________Raised: ____________________________________________Does the child live with mother and father: □ Yes □ No If not, describe: _____________________________________________Mother’s age: ____________________Education: _________________________Occupation: __________________________Father’s age: ____________________Education: _________________________Occupation: __________________________Family History:Is your child adopted? □ Yes □ No (if medical history of blood relatives known, describe below)Father:□ Alive, Age: _____________□ Deceased, Cause of Death: _____________Mother:□ Alive, Age: _____________□ Deceased, Cause of Death: _____________Does the child have any siblings:□ Yes □ No How many: ___________________________Please list any illnesses in the following family members:Father: _____________________________________________________________________________________Mother: _____________________________________________________________________________________Grandparents: ________________________________________________________________________________Brothers: ____________________________________________________________________________________Sisters: ______________________________________________________________________________________Children: _____________________________________________________________________________________Other: _______________________________________________________________________________________Pediatric Outpatient History QuestionnaireFamily History (cont’d):Does anyone in the family have neurologic problems:□ Yes □ No if Yes, describe: _________________________Does anyone in the family have psychiatric problems:□ Yes □ No if Yes, describe: _________________________Does anyone in the family have problems similar to your child’s problem: □ Yes □ No if Yes, describe: ____________________________________________________________________________________________________________________Past Medical History:Has your child ever been hospitalized:□ Yes □ No if Yes, describe: _________________________Immunization History:Are your child’s immunizations up to date: □ Yes □ NoHas your child ever had the following?Strep throat: □ Yes □ No if Yes, describe: ____________________Asthma: □ Yes □ No if Yes, describe: ____________________Heart problems: □ Yes □ No if Yes, describe: ____________________Lung problems: □ Yes □ No if Yes, describe: ____________________Kidney problems: □ Yes □ No if Yes, describe: ____________________Stomach problems: □ Yes □ No if Yes, describe: ____________________Colon problems: □ Yes □ No if Yes, describe: ____________________Depression: □ Yes □ No if Yes, describe: ____________________Psychiatric illness: □ Yes □ No if Yes, describe: ____________________Alcohol/drug abuse: □ Yes □ No if Yes, describe: ____________________Poisoning (with what): □ Yes □ No if Yes, describe: ____________________Endocrine disorder: □ Yes □ No if Yes, describe: ____________________Infectious disease: □ Yes □ No if Yes, describe: ____________________Lyme disease: □ Yes □ No if Yes, describe: ____________________Other: □ Yes □ No if Yes, describe: ____________________Attention Deficit Disorder: □ Yes □ No if Yes, describe: ____________________Stroke/TIA: □ Yes □ No if Yes, describe: ____________________Seizure: □ Yes □ No if Yes, describe: ____________________Migraine: □ Yes □ No if Yes, describe: ____________________Learning disability: □ Yes □ No if Yes, describe: ____________________Does your child have allergies (including medications): □ Yes □ NoIf yes, describe: ____________________________________Medication Names: _________________________________What medication is your child taking now from a non-Stony Brook physician?MedicationDoseFrequency__________________________________________________________________________________________________________________________________________Any medications recently stopped:_____________________________________________________________________ ................
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