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 infections Explain: _________________________________________________________ Medicines or drugs used during pregnancy: _____________________________________________________________________________________ Smoking while pregnant _______None _____ Moderate _____ Heavy Alcohol while pregnant _______ None _____ 1 per week Birth How 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 oxygen Did baby require: ________ special nursery _______blood transfusion ______ antibiotics _______ lights Did 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 Questionnaire

Family Background Ethnic origin/Race: Mother ________ Father: ________ __ Married __ Living together __ Separated __Divorced __ Single Child lives with: __ Both parents __Mother __ Father __ Guardian Other members of household: _____________________________________ Age of home or apartment? ____________ Any pets? ________________ Has any parent, brother or sister died? ______ Who? ________________ Cause of death? ____________________________ Age ________________ List family illnesses known and the family member: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Medical History Please 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 ______ ____Asthma ____ ___________ ____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 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 your child worn? ____ Glasses __ Contact lenses __ Dental braces __ Leg braces __ Corrective shoes __ Orthotics In shoes __ Other braces Does your child have any of the following: __ Frequent headaches __ Pinkeye __ Trouble hearing __ stuffy nose most of the time __ Chronic cough __ Heart murmur __ Frequent stomachaches __ Poor 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 __ Frequent 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 Development At 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________________________________________________ _________________________________________________________