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MAN: Patient Name:PEDIATRIC HEALTH HISTORY QUESTIONNAIRE(Patient Label)Name: Date: Home Phone: Parent / Guardian: Mother: Father: Other: Members of Household: Medication: Allergies: Past Medical History:

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What is members of household?

Members of household refers to individuals who reside in the same residence and are typically related by blood, marriage, or adoption.

Who is required to file members of household?

Usually the head of the household or the primary individual responsible for the residence is required to file members of household.

How to fill out members of household?

To fill out members of household, you will need to provide the names, relationships, ages, and other relevant information of each individual residing in the household.

What is the purpose of members of household?

The purpose of members of household is to accurately document and report the individuals living in a particular residence for various governmental and administrative purposes.

What information must be reported on members of household?

Information such as names, relationships, ages, and sometimes income levels or demographic data may need to be reported on members of household.

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