Initial Patient History

Birth History

Patient Name

Date of Birth

Birth Weight

oz

Length at Birth

Term

Yes No

Preterm

Yes No

Preterm

Type of Delivery

Vaginal Delivery C-Section

If C-Section, list reason

Was child exposed prenatally to

Smoke

Drugs

Alcohol

None

Pregnancy or Delivery Complications if any

Problems with baby after birth, if any

Length of hospital stay

Patient Birth History Reason Unknown

Adoption Foster care Other

Other

Social History

With Whom Does Patient Live

What type of home

Apartment Single Family House Mobile Home

Parents’ Marital Status

Married Divorced Single

Are there any smokers in the home?

No Yes

If yes, Whom?

Are there any pets in the home?

No Yes

How many?

What type of pet?

Dog

Cat

Fish

Bird

Other

Other

Medications

Current Medications (If yes, please list below)

Yes No

Medication

Dosage

Frequency

Medication

Dosage

Frequency

Medication

Dosage

Frequency

Medication

Dosage

Frequency

Medication

Dosage

Frequency

Drug Allergies?

No Yes

Medication & Reaction

Surgeries

No Surgeries

Yes No

Circumcision

Yes No

Date

Ear Tubes

Yes No Multiple

Most Recent Date

Tonsils/Adenoids

Yes No

Date

Other

Date

Hospitalizations

No Hospitalizations

Yes No

Reason

Age

Date

Reason

Age

Date

Reason

Age

Date

Reason

Age

Date

Past Medical History

No current or past health concerns

Yes No

Other

Family Medical History

None

Yes No

Other

Medical History Unknown

Maternal Family History

Paternal Family History

Your information will be encrypted.

Loading...