PediatricInitialHealthQuestionnaireDateofVisit：小儿初始健康问卷访问日期.pptVIP

Date of Visit: _____________________________Your Name: _____________________________Child’s 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 Information Child’s Date of Birth:_______________________________________________ ____Boy ____Girl BirthplaceCity/State________________________________________________________________ Hospital________________________________________ Other______________________________ Mother’s Name_________________________________ Birth Date__________________________ Occupation ____________________________________Ht________________ Wt______________ Father’s 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_________________________________________________________________ Pregnancy Number of pregnancies before this one________ How long was this pregnancy _______weeks? How many 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