Name Sheeza Fayyaz

History taking form questions

Personal Information
1. What is your name?
2. How old are you?
3. Gender
4. Date of Birth
5. With which ethnicity do you most closely identify with?
6. Where were you born?
7. Where do you currently live?
8. Do you practice any religion?
9. What is your marital status?
10. How would you like to express yourself?
11. Do you have any strengths or weaknesses?
Prenatal History
1. At what age did your parents get married?
2. At what age did they conceive you?
3. General health status of your parents at the age they conceived you?
4. Was the pregnancy planned or accidental?
5. Was the pregnancy artificially induced or naturally?
6. What was their reaction to this conception/pregnancy?
7. What was the duration of the pregnancy term?
8. Were there any emotional or physical issues that your mother went through during this
pregnancy?
9. Were there any complications with this pregnancy?
10. Was your mother on any significant medications or substances before or during the
pregnancy?
11. For how long was she on them before, during or after the pregnancy term?
12. Did your mother have any history of substance abuse or misuse before or during the
pregnancy?
13. Did any significant event happen in the life of your parents, especially your mother,
during pregnancy?
Perinatal History
1. Were the labor pains artificially induced or naturally?
2. What was the duration of labor pain before birth?
3. Was the delivery normal (vaginal) or caesarean?
4. Was there any medical difficulty for your mother during delivery?
5. Was her health compromised during the labor or delivery?
6. Did your mother suffer from any physical trauma or injury during or right after delivery?
7. Were you a healthy new-born or suffered from medical issues?
8. What was your color and weight when you were born?
9. Were you pre-mature, post-mature or a normal new-born baby?
10. Was there any imminency or delay of the first cry?
11. Was there any breathing issue with you right after birth?
12. Was there any reflexive issue with you after birth?
13. Was there any swallowing issue with you after birth?
14. Did you suffer from any physical trauma or injury during or right after delivery?
Post-Natal History
1. Were you able to hold your neck at the average age?
2. Were you able to sit with support at the average age?
3. Were you able to sit without support at the average age?
4. Were you able to start crawling at the average age?
5. Were you able to stand with support at the average age?
6. Were you able to stand without support at the average age?
7. Were you able to climb up and down the stairs at the average age?
8. Were you able to take your first step at the average age?
9. Were you able to walk properly at the average age?
10. Were you able to say your first word at the average age?
11. Were you able to talk properly at the average age?
12. Were your toilet-trained fully at the average age?
13. Did you experience any physical trauma or injury in the first year of birth?
14. Was there any physical difficulty during the first year of birth?
15. Any significant injuries, traumas, and even high-grade fever during first five years of
age?
16. What was the time-duration of that high-grade fever?
17. What was the severity of the high-grade fever?
18. Was any medical help sought for it?
19. At what time during the duration of it was the medical help sought?
Educational History
1. At what age did you start school?
2. What was your first reaction to school?
3. Did you suffer from any separation anxiety (from parents, siblings, family)?
4. Did you make friends easily in school?
5. Did you like attending school?
6. Did you share a good relationship with peers and instructors?
7. What was your favorite subject in school?
8. Were you more interested in academics or in extracurricular activities?
9. What subjects were you good at?
10. Did you struggle with any subject in school?
11. Did you struggle with anything in school?
12. Any significant achievements in your school?
13. Did you ever change school?
14. What was the reason for it?
15. How did you feel about this change?
16. Did you suffer from any physical or mental trauma in school?
17. Did you abuse or misuse any substance in school? (Such as cigarettes or anyt