GENERAL INFORMATION What is the child’s sex? ☐ Female ☐ Male Child’s Date of Birth_____________________________ current age Is your child adopted? ☐No ☐Yes If yes, at what age? Who is filling out this form? ☐Mother ☐Father ☐Other guardian (please explain relationship to child) __________________________ ☐Other (please explain) The child’s parents are: ☐Single ☐Married ☐Divorced ☐Separated but not divorced ☐Widowed ☐Living together but not married ☐Unknown Main adult contact for child Other adult contact for child Name: Name: Relation to child: ☐ Mother ☐ Father ☐ Other: ________________________ Relation to child: ☐ Mother ☐ Father ☐ Other: ________________________ Address: ☐ Same as child’s Street address: ____________________ City: ____________________________ State: ___________________________ Zip: ____________________________ Address: ☐ Same as child’s Street address: ____________________ City: ____________________________ State: ___________________________ Zip: ____________________________ Home Phone: Home Phone: Cell Phone: Cell phone: Work Phone: Work Phone:
5. What over-the-counter medicines, does your child take regularly? ☐ Vitamins ☐ Herbal medicine (please list) ☐ Other (please list) ☐ None, my child does not take any over-the-counter medicines regularly. 6. Does your child have any allergic reaction (bad effect) from any of the following? (Check all that apply.) ☐ Outside or Indoor allergies (for example: grass, pollen, cats …) ☐ Food Allergies (for example: peanuts, milk, wheat …) ☐ Medicine or shots (immunization). (Please list below.) ☐ No, my child has no allergies that I know of. Medicine child is allergic to: What happens when the child takes that medicine Example: Amoxicillin Diarrhea (runny poop) 7. Has your child had any of the following diseases? Measles ☐Yes ☐No ☐Don’t Know Mumps ☐Yes ☐No ☐Don’t Know Chicken Pox ☐Yes ☐No ☐Don’t Know Whooping Cough ☐Yes ☐No ☐Don’t Know Rubella ☐Yes ☐No ☐Don’t Know Rheumatic Fever ☐Yes ☐No ☐Don’t Know Scarlet Fever ☐Yes ☐No ☐Don’t Know 8. Please check any of the following medical problems that your child has ever had.
Has your child ever had: Ear infections ☐ Yes ☐ No Nose problems (sinus infections, nose bleeds) ☐ Yes ☐ No Eye problems (blurry vision, need to wear glasses) ☐ Yes ☐ No Hearing problems ☐ Yes ☐ No Mouth or throat problems (Strep throat, swallowing problems) ☐ Yes ☐ No Diarrhea (having frequent and runny bowel movements/poop) ☐ Yes ☐ No Constipation (problems having a bowel movement /poop) ☐ Yes ☐ No Throwing up (vomiting) ☐ Yes ☐ No Problems peeing (bed wetting, pain when peeing) ☐ Yes ☐ No Back problems (crooked back, back pain) ☐ Yes ☐ No Growing pains (bone or body pains due to growing) ☐ Yes ☐ No Muscle and bone problems (weak muscles, pain in joints) ☐ Yes ☐ No Skin problems (acne, flaking skin, rashes, hives) ☐ Yes ☐ No Seizures (shaking fits) ☐ Yes ☐ No ADD/ADHD (problems paying attention, sitting still) ☐ Yes ☐ No Sleeping problems (falling or staying asleep) ☐ Yes ☐ No Breathing problems (cough, asthma) ☐ Yes ☐ No Warts ☐ Yes ☐ No Jaundice (yellow skin) ☐ Yes ☐ No SHOTS 9. Has your child received immunizations (shots) in the past? ☐ No (If no, go to question #10.) ☐ Yes If yes, have you given this office a copy of the immunization (shots) records? ☐Yes (If Yes, go to question #10.) ☐No If not, please give us the name of the doctors’ offices or clinics where your child has received these shots so we can get the records. Doctor’s office/clinic name: Doctor’s office/clinic phone number: ABOUT MOM WHEN PREGNANT
☐ Less than 30 minutes ☐ 30 minutes to 1 hour ☐ Over 1 hour 29. About how many hours of TV does your child watch every day? ☐ Less than1 hour ☐ 1-3 hours ☐ More than 3 hours 30. About how many hours is your child on a computer every day? ☐ Less than 1 hour ☐ 1-3 hours ☐ More than 3 hours ☐ Does not have a computer 31. About how many hours does your child spend outside every day? ☐ Less than1 hour ☐ 1-3 hours ☐ More than 3 hours 32. About how many hours are spent reading with your child every day? ☐ Less than 15 minutes ☐ 15-30 minutes ☐ 30 minutes to1 hour ☐ More than 1 hour 33. Does your child wear a helmet when riding a bike, roller blading, skate boarding, etc.? ☐ Yes ☐ No ☐ Does not do activities like that 34. Does your child get buckled in a car seat or wear a seat belt when riding in a car? ☐Yes ☐ No 35. Do you have guns in the home? ☐Yes ☐ No If yes, are they locked up? ☐Yes ☐ No 36. What activities is your child involved in: ☐ Riding bike ☐T-ball/baseball ☐ Dance/movement ☐ Skate boarding ☐ Karate ☐ Video games ☐ Girl Scouts/Boy Scouts ☐ Soccer ☐ Playing a musical instrument ☐ Reading ☐ Playing with friends Other team sports ☐ Other activity(s) ☐ Too young to be involved in activities
37. Please list what your child typically eats and drinks in a day for: Breakfast Lunch Dinner Snacks FAMILY 38. Check all the people that the child lives with: ☐ Mother ☐ Father ☐ Brothers (how many? ) ☐ Sisters (how many? ) ☐ Other family members (list ) ☐ Friends or other people (list ) ☐ Animals ☐ Dogs (how many? ) ☐ Cats (how many? ) ☐ Other animals 39. What medical problems do people in the child’s family have? Family Member Medical Problems Mother: ☐ Depression ☐ Anxiety (nerve) problems ☐ Learning disability ☐ Overweight ☐ High blood pressure ☐ Diabetes (sugar) ☐ Cancer ☐ Heart problems Other: Father: ☐Depression ☐Anxiety (nerve) problems ☐Learning disability ☐Overweight ☐High blood pressure ☐Diabetes (sugar) ☐Cancer ☐Heart problems Other: Sisters: ☐ Depression ☐ Anxiety (nerve) problems ☐ Learning disability ☐ Overweight ☐ High blood pressure ☐ Diabetes (sugar) ☐ Cancer ☐ Heart problems Other: Brothers: ☐ Depression ☐ Anxiety (nerve) problems ☐ Learning disability ☐ Overweight ☐ High blood pressure ☐ Diabetes (sugar) ☐ Cancer ☐ Heart problems Other: