Family Health Assessment

Family Health Assessment
Patient's Name*

First NameLast Name
Patient's DOB*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Your Email
example@example.com
There are many factors that can impact your child's overall health. Please answer these questions regarding your family and household to the best of your ability. Thank you for taking an active role in your child's health care.
Who does your child live with? (check all that apply)*

MotherFatherStepmotherStepfatherGuardianGrandparent(s)Brother(s)Sister(s)Other
Does your child have any other regular caregivers?*

YesNo
Since your child's last well visit, have there been any changes in your family or household, such as (check all that apply)

MarriageSeparation/ DivorceBirthsDeathsSerious Illness/ InjuryNew SchoolNew HomeLoss Of JobOther
Are there any new stressors in your family or household?*

YesNo
If "Yes", please specify
Are there any new medical problems in your family?*

YesNo
If "Yes", please specify
Does anyone in your family or household have a history of mental illness?*

YesNo
If "Yes", please specify
Does anyone in your family or household smoke?*

YesNo
If "Yes", please specify
Do you have any concerns about drug and/or alcohol problems in your family or household?*

YesNo
If "Yes", please specify
Do you have any concerns about your safety or your child's safety in your household?*

YesNo
If "Yes", please specify
Are there any obstacles in your family or household to maintaining a healthy lifestyle?*

YesNo
If "Yes", please specify
Should be Empty: