Medical/Family History Questionnaire

M F

Pregnancy and Birth History

Yes No

Yes No

Yes No

Yes No

Vaginal C-section

Yes No

Yes No

Psychosocial History

Rent? Own? Shelter?

Family History

Has anyone in the family (parents, grand-parents, aunts/uncles, sisters/brothers) had:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Medical History

Has your child ever had:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No