Sample outline of child history questionnaire, Biology

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Sample Outline of Child History Questionnaire

Basic identifying data:

  • Child's name
  • Date of birth
  • Date of evaluation
  • Person referring for evaluation
  • Person filling out the questionnaire
  • Child's behavioural problems for which being referred to

Referral information:

  • Reason for referral
  • Circumstances/factor judged responsible for this problem
  • Child's strength
  • Child's weakness
  • Do parents agree about the nature and causes of the problem?

Family information:

  • Address
  • Telephone
  • Parents (name, age, education, marital status)
  • Child's natural, adopted, or fosters status
  • Siblings (name, age)
  • Other's living in home
  • Approximate family income
  • Father's occupation
  • Mother's occupation
  • Significant family or marital conflict

Pregnancy, birth history, neonatal period:

  • Age of mother at delivery
  • Health problems of mother during pregnancy
  • Length of labour and any complications
  • Delivery type (vaginal, Caesarean) and any complications
  • Term length (full, premature, number of week's gestation)
  • Birth weight and height
  • Condition of baby (e.g., baby breathed spontaneously, Apgar scores)
  • Type of nursery (e.g. normal new-born, paediatric intensive care)
  • Days until discharge from the hospital after birth
  • Medical problems after discharge (e.g., jaundice, fever)
  • Any problems in the first few months

 


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