Name: _____________________________________
Health Status Questionnaire – 7-10 yr
Date of birth: _______________
Child lives with:
mother
father
mother&father
other:_________________
Discipline:
verbal
grounding
spanking
other: _______________________
School:
public
private
chartered
home school
st
nd
rd
th
th
Grade:
K
1
2
3
4
5
6th
Performance:
excellent good
fair
poor
failing
Brush teeth:
Passive smoke exposure:
Sunscreen:
Helmet use:
Firearms/guns in home:
Y
Y
Y
Y
Y
N
N
N
N
N
Visit with dentist:
Car seat/belt use:
Insect protection:
ATV/motorcycle:
Locked away: Y
N
Tuberculosis (Tb) Screen Questions:
Has your child ever received BCG (a Tb vaccine given in some
foreign countries)?
Has there ever been tuberculosis/Tb in any household member?
Was your child born or traveled for longer than 2 weeks to a country
at high risk for tuberculosis (countries other than U.S.,
Canada, Australia, New Zealand or western Europe)?
Aware of risks of strangers:
Y
N
Aware of sexual privacy:
Y
Y
Y
Y
N
N
N
N
Y
Y
N
N
Y
N
Y
N
Eating habits:
___ regular meals
___ skips meals
___ snacks
___ grazes
___ picky
___adequate fruits/veggies
___ vegetarian
___ fast food > 2x week
Milk/dairy products: ___ times per day
Juice: ___ oz per day ___ vitamins
Activity: regular exercise active
sports
sedentary cannot tolerate exercise
Voiding habits:
normal
bedwetting
accidents during day
Stool pattern:
daily
regular
irregular
hard
runny
constipated
holds stool
accidents
Sleep:
9-10 hours
<8 hours
difficulty falling asleep
wakes at night
nightmares
sleepwalk
Child’s temperament: happy irritable hyperactive odd/concerning shy anxious
Do you have any concerns about your child’s vision or hearing?
Do you limit your child to no more than 1-2hrs of TV/video games?
Dyslipidemia screen:
Child’s parents/grandparents had stroke/ heart attack before age 55?
Child’s parent with elevated cholesterol(>240) or taking
cholesterol medicine?
(continue on back)
Y
Y
N
N
Y
N
Y
N
Review of Systems:
Const
fever
y n
fatigue
y n
weight loss y n
weight gain y n
irritability
y n
ENT/eye
sore throat
y n
stuffy nose
y n
runny nose
y n
earache
y n
eye redness y n
eye discharge y n
eye swelling y n
lazy eye
y n
Resp
cough
y n
night cough y n
exercise coughy n
wheezing
y n
labor breathingy n
CV
turns blue
y n
tires easily
y n
exercise
dizziness
y n
palpitations y n
GI
stomachache y
nausea
y
vomiting
y
diarrhea
y
constipation y
bloody stool y
Skin
dry
y
rash
y
eczema
y
suspicious
lesion
y
wart
y
Musc-skel
bowed legs y
in-toeing
y
joint pain
y
back pain
y
limp
y
Neuro
learning probs y
stiffness
y
weakness
y
toe-walking y
headaches
y
seizures
y
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
Heme
excessive bleeding
excessive bruising
pale
swollen
lymph nodes
GU
genital swelling
genital redness
discharge
Allergy
hay fever
sinus congestion
food reaction
hives
Mental health
anxiety
mood swings
depression
suicidal thought
racing thought
anger
difficulty
concentrating
y
y
y
n
n
n
y
n
y
y
y
n
n
n
y
y
y
y
n
n
n
n
y
y
y
y
y
y
n
n
n
n
n
n
y
n
Do you have any concerns about your child? ___________________________________
________________________________________________________________________
If your child has asthma, history of wheezing or uses inhalers/breathing treatments,
please answer the following questions:
Cough/wheezing:
0-2 days/week
>2 days/week
daily
throughout day
Nighttime cough: 0-1 night/month 2-3 nights/month 4 nights/month >1 night/week
Interferes with normal activity:
no limitations
minor
some
extreme
Rescue inhaler (albuterol,Proair,Xopenex,Ventolin,Proventil) use:
0-2 days/week
>2 days/week
daily
several times/day
Oral steroid courses:
0-1X/year
2-3X/year
>3X/year
Asthma hospitalizations past 6 months:
0
1
2
3