Pregnancy/Neonatal Period
Is the child yours by:
Delevery by
Was your child premature
Has your child ever been treated for or diagnosed with: (explain)
Has your child ever been hospitalize
Was your child breastfed
Has your child had any unusual feeding/dietary problems?
Current milk intake
Who lives in the household with the child?
Child's parents are:
Childcare
Do any household members smoke?
How many hours per day does your child spend:
Any concerns about school performance?
Any concerns about peer or teacher relationship?
Sports/exercise
Do any family members have any of the following conditions:
Mother
Father
Sibling
Grandparent
Constitutional Gastrointestinal
Ear, Nose, and Throat Cardiovascular
Respiratory
Musculoskeletal Neurologic
Other (eye,skin,blood)
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